C-CDA on FHIR
1.2.0 - STU 1
C-CDA on FHIR
1.2.0 - STU 1
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
| Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/History-and-Physical | Version: 1.2.0 | |||
| Active as of 2024-03-12 | Computable Name: HistoryAndPhysical | |||
A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual’s health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient’s lifestyle, habits, and diseases among family members. The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician’s assessment of the patient’s situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.
2024 Publication of C-CDA ↔ FHIR US Core MappingThe 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  type | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
  Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
   section:allergies_and_intolerances_section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
  title | S | 1..1 | string | title |
 code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: At least the following |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text | S | 1..1 | Narrative | text |
 Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
 entry:allergies_and_intolerances_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:family_history_section | S | 1..1 | BackboneElement | Family History Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Family History Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:family_history_section_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:general_status_section | S | 1..1 | BackboneElement | General Status Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | General Status Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |
 text | S | 1..1 | Narrative | This section contains only human readable content |
| section:medications_section | S | 1..1 | BackboneElement | Medications Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:medications_section_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| section:past_medical_history_section | S | 0..1 | BackboneElement | Past Medical History Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:past_medical_history_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:physical_exam_section | 1..1 | BackboneElement | Physical Exam Section | |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Physical Findings Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:physical_exam_entry | S | 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 | S | 1..1 | BackboneElement | Results Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:results_entry | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| section:review_of_systems_section | S | 1..1 | BackboneElement | Review of Systems Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Review of Systems Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:social_history_section | S | 1..1 | BackboneElement | Social History Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Social History Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:smoking_status_entry | S | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status |
| section:vital_signs_section | S | 1..1 | BackboneElement | Vital Signs Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Vital Signs Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:vital_signs_entry | S | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:history_of_present_illness_section | S | 0..1 | BackboneElement | History of Present Illness Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of Present Illness Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:assessment_and_plan_section | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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 | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessment and Plan Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:assessment_and_plan_entry | S | 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 | S | 0..1 | BackboneElement | Assessment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessments Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:chief_complaint_and_reason_for_visit_section | S | 0..1 | BackboneElement | Chief 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 | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Chief Complaint Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:immunizations_section | S | 0..1 | BackboneElement | Immunizations Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Immunizations Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:immunizations_entry | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section | |
| section:plan_of_treatment_section | S | 0..1 | BackboneElement | Plan of Treatment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | S | 1..1 | Narrative | text |
| 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:problem_section | S | 0..1 | BackboneElement | Problem Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Problem List Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:problem_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:procedures_section | S | 0..1 | BackboneElement | Procedures Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of Procedures Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:procedures_entry | S | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section |
| section:reason_for_visit_section | S | 0..1 | BackboneElement | Reason for Visit Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Reason for Visit Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
 section:instructions_section | S | 0..1 | BackboneElement | Instructions Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Instructions Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.type | required | HPDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22from this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
 identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | ||||
 subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
 Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
 attester:All Slices | Content/Rules for all slices | |||||||
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| Slices for section | C | 0..* | BackboneElement | Composition 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| section:allergies_and_intolerances_section | C | 1..1 | BackboneElement | Allergies 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:allergies_and_intolerances_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| section:family_history_section | SC | 1..1 | BackboneElement | Family 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Family History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:family_history_section_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| section:general_status_section | SC | 1..1 | BackboneElement | General 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | General Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:medications_section | SC | 1..1 | BackboneElement | Medications 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:medications_section_entry | SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section | ||||
| section:past_medical_history_section | SC | 0..1 | BackboneElement | Past 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:past_medical_history_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| section:physical_exam_section | C | 1..1 | BackboneElement | Physical 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Physical Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:physical_exam_entry | SC | 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 | SC | 1..1 | BackboneElement | Results 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:results_entry | SC | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section | ||||
| section:review_of_systems_section | SC | 1..1 | BackboneElement | Review 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Review of Systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:social_history_section | SC | 1..1 | BackboneElement | Social 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Social History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:smoking_status_entry | SC | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status | ||||
| section:vital_signs_section | SC | 1..1 | BackboneElement | Vital 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Vital Signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:vital_signs_entry | SC | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| section:history_of_present_illness_section | SC | 0..1 | BackboneElement | History 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Present Illness Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:assessment_and_plan_section | SC | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessment and Plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
| entry:assessment_and_plan_entry | SC | 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 | SC | 0..1 | BackboneElement | Assessment 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessments Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:chief_complaint_and_reason_for_visit_section | SC | 0..1 | BackboneElement | Chief 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:chief_complaint_section | SC | 0..1 | BackboneElement | Chief 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:immunizations_section | SC | 0..1 | BackboneElement | Immunizations 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Immunizations Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:immunizations_entry | C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section | ||||
| section:plan_of_treatment_section | SC | 0..1 | BackboneElement | Plan 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:sliceEntry | C | 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:problem_section | SC | 0..1 | BackboneElement | Problem 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Problem List Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:problem_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| section:procedures_section | SC | 0..1 | BackboneElement | Procedures 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:procedures_entry | SC | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section | ||||
| section:reason_for_visit_section | SC | 0..1 | BackboneElement | Reason 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:instructions_section | SC | 0..1 | BackboneElement | Instructions 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Instructions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | required | HPDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22from this IG | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:family_history_section.code | example | Pattern: LOINC code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:general_status_section.code | example | Pattern: LOINC code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:medications_section.code | example | Pattern: LOINC code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.code | example | Pattern: LOINC code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:results_section.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.code | example | Pattern: LOINC code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:social_history_section.code | example | Pattern: LOINC code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.code | example | Pattern: LOINC code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_section.code | example | Pattern: LOINC code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.code | example | Pattern: LOINC code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.code | example | Pattern: LOINC code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:problem_section.code | example | Pattern: LOINC code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:procedures_section.code | example | Pattern: LOINC code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.code | example | Pattern: LOINC code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:instructions_section.code | example | Pattern: LOINC code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
| Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | C | 0..* | BackboneElement | Composition 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 | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:allergies_and_intolerances_section | C | 1..1 | BackboneElement | Allergies 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:allergies_and_intolerances_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:family_history_section | SC | 1..1 | BackboneElement | Family 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Family History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:family_history_section_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:general_status_section | SC | 1..1 | BackboneElement | General 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | General Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:medications_section | SC | 1..1 | BackboneElement | Medications 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:medications_section_entry | SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:past_medical_history_section | SC | 0..1 | BackboneElement | Past 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:past_medical_history_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:physical_exam_section | C | 1..1 | BackboneElement | Physical 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Physical Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:physical_exam_entry | SC | 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. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:results_section | SC | 1..1 | BackboneElement | Results 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:results_entry | SC | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:review_of_systems_section | SC | 1..1 | BackboneElement | Review 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Review of Systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:social_history_section | SC | 1..1 | BackboneElement | Social 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Social History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:smoking_status_entry | SC | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:vital_signs_section | SC | 1..1 | BackboneElement | Vital 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Vital Signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:vital_signs_entry | SC | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:history_of_present_illness_section | SC | 0..1 | BackboneElement | History 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Present Illness Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:assessment_and_plan_section | SC | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessment and Plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
| entry:assessment_and_plan_entry | SC | 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. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:assessment_section | SC | 0..1 | BackboneElement | Assessment 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessments Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:chief_complaint_and_reason_for_visit_section | SC | 0..1 | BackboneElement | Chief 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:chief_complaint_section | SC | 0..1 | BackboneElement | Chief 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:immunizations_section | SC | 0..1 | BackboneElement | Immunizations 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Immunizations Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:immunizations_entry | C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:plan_of_treatment_section | SC | 0..1 | BackboneElement | Plan 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:sliceEntry | C | 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. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:problem_section | SC | 0..1 | BackboneElement | Problem 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Problem List Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:problem_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:procedures_section | SC | 0..1 | BackboneElement | Procedures 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:procedures_entry | SC | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:reason_for_visit_section | SC | 0..1 | BackboneElement | Reason 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:instructions_section | SC | 0..1 | BackboneElement | Instructions 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Instructions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | required | HPDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22from this IG | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:family_history_section.code | example | Pattern: LOINC code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:family_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:family_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:family_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:general_status_section.code | example | Pattern: LOINC code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:general_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:general_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:general_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:medications_section.code | example | Pattern: LOINC code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:medications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:medications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:medications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.code | example | Pattern: LOINC code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:past_medical_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:results_section.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:results_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:results_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:results_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.code | example | Pattern: LOINC code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:social_history_section.code | example | Pattern: LOINC code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:social_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:social_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:social_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.code | example | Pattern: LOINC code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:assessment_section.code | example | Pattern: LOINC code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:assessment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.code | example | Pattern: LOINC code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.code | example | Pattern: LOINC code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:immunizations_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:problem_section.code | example | Pattern: LOINC code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:problem_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:problem_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:problem_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:procedures_section.code | example | Pattern: LOINC code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:procedures_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:procedures_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:procedures_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.code | example | Pattern: LOINC code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:instructions_section.code | example | Pattern: LOINC code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:instructions_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:instructions_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:instructions_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Summary
Mandatory: 36 elements (36 nested mandatory elements)
Must-Support: 93 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| type | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
| Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
| section:allergies_and_intolerances_section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:allergies_and_intolerances_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:family_history_section | S | 1..1 | BackboneElement | Family History Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Family History Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:family_history_section_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:general_status_section | S | 1..1 | BackboneElement | General Status Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | General Status Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:medications_section | S | 1..1 | BackboneElement | Medications Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:medications_section_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| section:past_medical_history_section | S | 0..1 | BackboneElement | Past Medical History Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:past_medical_history_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:physical_exam_section | 1..1 | BackboneElement | Physical Exam Section | |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Physical Findings Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:physical_exam_entry | S | 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 | S | 1..1 | BackboneElement | Results Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:results_entry | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| section:review_of_systems_section | S | 1..1 | BackboneElement | Review of Systems Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Review of Systems Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:social_history_section | S | 1..1 | BackboneElement | Social History Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Social History Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:smoking_status_entry | S | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status |
| section:vital_signs_section | S | 1..1 | BackboneElement | Vital Signs Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Vital Signs Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:vital_signs_entry | S | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:history_of_present_illness_section | S | 0..1 | BackboneElement | History of Present Illness Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of Present Illness Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:assessment_and_plan_section | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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 | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessment and Plan Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:assessment_and_plan_entry | S | 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 | S | 0..1 | BackboneElement | Assessment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessments Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:chief_complaint_and_reason_for_visit_section | S | 0..1 | BackboneElement | Chief 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 | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Chief Complaint Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:immunizations_section | S | 0..1 | BackboneElement | Immunizations Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Immunizations Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:immunizations_entry | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section | |
| section:plan_of_treatment_section | S | 0..1 | BackboneElement | Plan of Treatment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | S | 1..1 | Narrative | text |
| 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:problem_section | S | 0..1 | BackboneElement | Problem Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Problem List Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:problem_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:procedures_section | S | 0..1 | BackboneElement | Procedures Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of Procedures Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:procedures_entry | S | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section |
| section:reason_for_visit_section | S | 0..1 | BackboneElement | Reason for Visit Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Reason for Visit Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:instructions_section | S | 0..1 | BackboneElement | Instructions Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Instructions Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.type | required | HPDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22from this IG |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | ||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
| Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| Slices for section | C | 0..* | BackboneElement | Composition 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| section:allergies_and_intolerances_section | C | 1..1 | BackboneElement | Allergies 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:allergies_and_intolerances_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| section:family_history_section | SC | 1..1 | BackboneElement | Family 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Family History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:family_history_section_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| section:general_status_section | SC | 1..1 | BackboneElement | General 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | General Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:medications_section | SC | 1..1 | BackboneElement | Medications 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:medications_section_entry | SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section | ||||
| section:past_medical_history_section | SC | 0..1 | BackboneElement | Past 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:past_medical_history_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| section:physical_exam_section | C | 1..1 | BackboneElement | Physical 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Physical Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:physical_exam_entry | SC | 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 | SC | 1..1 | BackboneElement | Results 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:results_entry | SC | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section | ||||
| section:review_of_systems_section | SC | 1..1 | BackboneElement | Review 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Review of Systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:social_history_section | SC | 1..1 | BackboneElement | Social 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Social History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:smoking_status_entry | SC | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status | ||||
| section:vital_signs_section | SC | 1..1 | BackboneElement | Vital 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Vital Signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:vital_signs_entry | SC | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| section:history_of_present_illness_section | SC | 0..1 | BackboneElement | History 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Present Illness Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:assessment_and_plan_section | SC | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessment and Plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
| entry:assessment_and_plan_entry | SC | 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 | SC | 0..1 | BackboneElement | Assessment 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessments Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:chief_complaint_and_reason_for_visit_section | SC | 0..1 | BackboneElement | Chief 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:chief_complaint_section | SC | 0..1 | BackboneElement | Chief 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:immunizations_section | SC | 0..1 | BackboneElement | Immunizations 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Immunizations Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:immunizations_entry | C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section | ||||
| section:plan_of_treatment_section | SC | 0..1 | BackboneElement | Plan 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:sliceEntry | C | 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:problem_section | SC | 0..1 | BackboneElement | Problem 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Problem List Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:problem_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| section:procedures_section | SC | 0..1 | BackboneElement | Procedures 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:procedures_entry | SC | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section | ||||
| section:reason_for_visit_section | SC | 0..1 | BackboneElement | Reason 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| section:instructions_section | SC | 0..1 | BackboneElement | Instructions 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Instructions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | required | HPDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22from this IG | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:family_history_section.code | example | Pattern: LOINC code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:general_status_section.code | example | Pattern: LOINC code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:medications_section.code | example | Pattern: LOINC code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.code | example | Pattern: LOINC code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:results_section.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.code | example | Pattern: LOINC code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:social_history_section.code | example | Pattern: LOINC code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.code | example | Pattern: LOINC code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_section.code | example | Pattern: LOINC code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.code | example | Pattern: LOINC code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.code | example | Pattern: LOINC code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:problem_section.code | example | Pattern: LOINC code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:procedures_section.code | example | Pattern: LOINC code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.code | example | Pattern: LOINC code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:instructions_section.code | example | Pattern: LOINC code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | 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 | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
| Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | C | 0..* | BackboneElement | Composition 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 | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:allergies_and_intolerances_section | C | 1..1 | BackboneElement | Allergies 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:allergies_and_intolerances_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:family_history_section | SC | 1..1 | BackboneElement | Family 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Family History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:family_history_section_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:general_status_section | SC | 1..1 | BackboneElement | General 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | General Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:medications_section | SC | 1..1 | BackboneElement | Medications 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:medications_section_entry | SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:past_medical_history_section | SC | 0..1 | BackboneElement | Past 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:past_medical_history_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:physical_exam_section | C | 1..1 | BackboneElement | Physical 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Physical Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:physical_exam_entry | SC | 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. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:results_section | SC | 1..1 | BackboneElement | Results 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:results_entry | SC | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:review_of_systems_section | SC | 1..1 | BackboneElement | Review 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Review of Systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:social_history_section | SC | 1..1 | BackboneElement | Social 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Social History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:smoking_status_entry | SC | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:vital_signs_section | SC | 1..1 | BackboneElement | Vital 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Vital Signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:vital_signs_entry | SC | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:history_of_present_illness_section | SC | 0..1 | BackboneElement | History 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Present Illness Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:assessment_and_plan_section | SC | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessment and Plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
| entry:assessment_and_plan_entry | SC | 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. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:assessment_section | SC | 0..1 | BackboneElement | Assessment 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Assessments Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:chief_complaint_and_reason_for_visit_section | SC | 0..1 | BackboneElement | Chief 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:chief_complaint_section | SC | 0..1 | BackboneElement | Chief 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Chief Complaint Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:immunizations_section | SC | 0..1 | BackboneElement | Immunizations 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Immunizations Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:immunizations_entry | C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:plan_of_treatment_section | SC | 0..1 | BackboneElement | Plan 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:sliceEntry | C | 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. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:problem_section | SC | 0..1 | BackboneElement | Problem 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Problem List Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:problem_entry | SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:procedures_section | SC | 0..1 | BackboneElement | Procedures 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | History of Procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:procedures_entry | SC | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:reason_for_visit_section | SC | 0..1 | BackboneElement | Reason 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Reason for Visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:instructions_section | SC | 0..1 | BackboneElement | Instructions 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Instructions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | required | HPDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22from this IG | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:family_history_section.code | example | Pattern: LOINC code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:family_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:family_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:family_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:general_status_section.code | example | Pattern: LOINC code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:general_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:general_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:general_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:medications_section.code | example | Pattern: LOINC code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:medications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:medications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:medications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.code | example | Pattern: LOINC code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:past_medical_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:past_medical_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:results_section.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:results_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:results_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:results_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.code | example | Pattern: LOINC code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:social_history_section.code | example | Pattern: LOINC code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:social_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:social_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:social_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.code | example | Pattern: LOINC code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:history_of_present_illness_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:assessment_section.code | example | Pattern: LOINC code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:assessment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:assessment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.code | example | Pattern: LOINC code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:chief_complaint_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.code | example | Pattern: LOINC code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:immunizations_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:immunizations_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:problem_section.code | example | Pattern: LOINC code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:problem_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:problem_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:problem_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:procedures_section.code | example | Pattern: LOINC code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:procedures_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:procedures_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:procedures_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.code | example | Pattern: LOINC code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:instructions_section.code | example | Pattern: LOINC code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:instructions_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:instructions_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:instructions_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:medications_section, Composition.section:past_medical_history_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:history_of_present_illness_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:immunizations_section, Composition.section:plan_of_treatment_section, Composition.section:problem_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:instructions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Summary
Mandatory: 36 elements (36 nested mandatory elements)
Must-Support: 93 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Cross-Group Projects. Package hl7.fhir.us.ccda#1.2.0 based on FHIR 4.0.1. Generated 2024-03-12
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