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 2.0.0-ballot 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

• Content
• Detailed Descriptions
• Mappings
• XML
• JSON
• TTL

Resource Profile: Operative Note

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

Usage:

• Examples for this Resource Profile: Composition/Operative-Note-Example

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	USRealmHeader	A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
language	S	1..1	code	language Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
versionNumber		0..*	string	Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
version_number_extension	S	0..1	integer	Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
performer_extension	S	0..*	Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)	performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
authorization_extension	S	0..*	Reference(Consent)	authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
order_extension	S	0..*	Reference(ServiceRequest)	authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	1..1	Identifier	identifier ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	type Binding: SurgicalOperationNoteDocumentTypeCode (required) ele-1: All FHIR elements must have a @value or children
subject	SΣ	0..1	Reference(US Core Patient Profile | Group)	Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Context of the Composition ele-1: All FHIR elements must have a @value or children
date	SΣ	1..1	dateTime	date ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children
title	SΣ	1..1	string	Document Title ele-1: All FHIR elements must have a @value or children
Slices for attester		0..*	BackboneElement	Attests to accuracy of composition Slice: Unordered, Open by value:mode ele-1: All FHIR elements must have a @value or children
attester:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children
attester:legal_attester	S	0..1	BackboneElement	attester ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: legal
party	S	1..1	Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)	party ele-1: All FHIR elements must have a @value or children
attester:professional_attester	S	0..*	BackboneElement	attester ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: professional
party	S	1..1	Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)	party ele-1: All FHIR elements must have a @value or children
attester:personal_attester	S	0..*	BackboneElement	attester ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: personal
party	S	1..1	Reference(US Core Patient Profile | RelatedPerson)	party ele-1: All FHIR elements must have a @value or children
custodian	SΣ	1..1	Reference(US Core Organization Profile)	custodian ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
section:anesthesia_section	SC	1..1	BackboneElement	Anesthesia 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Anesthesia Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59774-0
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:anesthesia_entry	SC	0..*	Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:complications_section	SC	1..1	BackboneElement	Complications 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Complications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 55109-3
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:complications_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:preoperative_diagnosis_section	SC	1..1	BackboneElement	Preoperative Diagnosis 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Preoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10219-4
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:preoperative_diagnosis_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:procedure_estimated_blood_loss_section	SC	1..1	BackboneElement	Procedure Estimated Blood Loss 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Estimated Blood Loss Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59770-8
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:procedure_findings_section	SC	1..1	BackboneElement	Procedure Findings 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59776-5
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:procedure_findings_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:procedure_specimens_taken_section	SC	1..1	BackboneElement	Procedure Specimens Taken 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Specimens Taken Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59773-2
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:postoperative_diagnosis_section	SC	1..1	BackboneElement	Postoperative Diagnosis 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Postoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10218-6
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:procedure_description_section	SC	1..1	BackboneElement	Procedure Description 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title		1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Description Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29554-3
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:operative_note_surgical_procedure_section	SC	0..1	BackboneElement	Operative Note Surgical Procedure 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Operative Note Surgical Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10223-6
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:operative_note_fluids_section	SC	0..1	BackboneElement	Operative Note Fluids 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10216-0
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
Slices for entry	SC	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children
section:planned_procedure_section	SC	0..1	BackboneElement	Planned Procedure 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Planned Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59772-4
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:planned_procedure_entry	SC	0..*	Reference(ServiceRequest)	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children
section:procedure_disposition_section	SC	0..1	BackboneElement	Procedure Disposition 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Disposition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59775-7
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:procedure_indications_section	SC	0..1	BackboneElement	Procedure Indications 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Indications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59768-2
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:problem_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:procedure_implants_section	SC	0..1	BackboneElement	Procedure Implants 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Implants Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59771-6
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:surgical_drains_section	SC	0..1	BackboneElement	Surgical Drains 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11537-8
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	required	SurgicalOperationNoteDocumentTypeCode http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 from this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:legal_attester.mode	required	Fixed Value: legal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:professional_attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:personal_attester.mode	required	Fixed Value: personal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.section:anesthesia_section.code	example	Pattern: LOINC Code 59774-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:complications_section.code	example	Pattern: LOINC Code 55109-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:preoperative_diagnosis_section.code	example	Pattern: LOINC Code 10219-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code	example	Pattern: LOINC Code 59770-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_findings_section.code	example	Pattern: LOINC Code 59776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_specimens_taken_section.code	example	Pattern: LOINC Code 59773-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:postoperative_diagnosis_section.code	example	Pattern: LOINC Code 10218-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_description_section.code	example	Pattern: LOINC Code 29554-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.code	example	Pattern: LOINC Code 10223-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_fluids_section.code	example	Pattern: LOINC Code 10216-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:plan_of_treatment_section.code	example	Pattern: LOINC Code 18776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:planned_procedure_section.code	example	Pattern: LOINC Code 59772-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_disposition_section.code	example	Pattern: LOINC Code 59775-7 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_indications_section.code	example	Pattern: LOINC Code 59768-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_implants_section.code	example	Pattern: LOINC Code 59771-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:surgical_drains_section.code	example	Pattern: LOINC Code 11537-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	USRealmHeader	A set of resources composed into a single coherent clinical statement with clinical attestation
type	S	1..1	CodeableConcept	type Binding: SurgicalOperationNoteDocumentTypeCode (required)
Slices for section		0..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code
section:anesthesia_section	S	1..1	BackboneElement	Anesthesia Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Anesthesia 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: 59774-0
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:anesthesia_entry	S	0..*	Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)	A reference to data that supports this section
section:complications_section	S	1..1	BackboneElement	Complications Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Complications 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: 55109-3
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:complications_entry	S	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section
section:preoperative_diagnosis_section	S	1..1	BackboneElement	Preoperative Diagnosis Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Preoperative Diagnosis 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: 10219-4
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:preoperative_diagnosis_entry	S	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section
section:procedure_estimated_blood_loss_section	S	1..1	BackboneElement	Procedure Estimated Blood Loss Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Estimated Blood Loss 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: 59770-8
text	S	1..1	Narrative	This section contains only human readable content
section:procedure_findings_section	S	1..1	BackboneElement	Procedure Findings Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure 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: 59776-5
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:procedure_findings_entry	S	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section
section:procedure_specimens_taken_section	S	1..1	BackboneElement	Procedure Specimens Taken Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Specimens Taken 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: 59773-2
text	S	1..1	Narrative	This section contains only human readable content
section:postoperative_diagnosis_section	S	1..1	BackboneElement	Postoperative Diagnosis Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Postoperative Diagnosis 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: 10218-6
text	S	1..1	Narrative	This section contains only human readable content
section:procedure_description_section	S	1..1	BackboneElement	Procedure Description Section
title		1..1	string	title
code	S	1..1	CodeableConcept	Procedure Description 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: 29554-3
text	S	1..1	Narrative	This section contains only human readable content
section:operative_note_surgical_procedure_section	S	0..1	BackboneElement	Operative Note Surgical Procedure Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Operative Note Surgical Procedure 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: 10223-6
text	S	1..1	Narrative	This section contains only human readable content
section:operative_note_fluids_section	S	0..1	BackboneElement	Operative Note Fluids Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Operative Note Fluids 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: 10216-0
text	S	1..1	Narrative	This section contains only human readable content
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	S	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:planned_procedure_section	S	0..1	BackboneElement	Planned Procedure Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Planned Procedure 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: 59772-4
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry	S	0..*	Reference(ServiceRequest)	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:procedure_disposition_section	S	0..1	BackboneElement	Procedure Disposition Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Disposition 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: 59775-7
text	S	1..1	Narrative	This section contains only human readable content
section:procedure_indications_section	S	0..1	BackboneElement	Procedure Indications Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Indications 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: 59768-2
text	S	1..1	Narrative	This section contains only human readable content
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:procedure_implants_section	S	0..1	BackboneElement	Procedure Implants Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Implants 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: 59771-6
text	S	1..1	Narrative	This section contains only human readable content
section:surgical_drains_section	S	0..1	BackboneElement	Surgical Drains Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Surgical Drains 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: 11537-8
text	S	1..1	Narrative	This section contains only human readable content
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	required	SurgicalOperationNoteDocumentTypeCode http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 from 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
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. Additional Bindings Purpose AllLanguages Max Binding
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	type Binding: SurgicalOperationNoteDocumentTypeCode (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:anesthesia_section	SC	1..1	BackboneElement	Anesthesia 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	Anesthesia 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: 59774-0
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:anesthesia_entry	SC	0..*	Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | 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:complications_section	SC	1..1	BackboneElement	Complications 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	Complications 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: 55109-3
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:complications_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:preoperative_diagnosis_section	SC	1..1	BackboneElement	Preoperative Diagnosis 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	Preoperative Diagnosis 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: 10219-4
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:preoperative_diagnosis_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:procedure_estimated_blood_loss_section	SC	1..1	BackboneElement	Procedure Estimated Blood Loss 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	Procedure Estimated Blood Loss 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: 59770-8
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:procedure_findings_section	SC	1..1	BackboneElement	Procedure Findings 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	Procedure 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: 59776-5
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:procedure_findings_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:procedure_specimens_taken_section	SC	1..1	BackboneElement	Procedure Specimens Taken 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	Procedure Specimens Taken 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: 59773-2
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:postoperative_diagnosis_section	SC	1..1	BackboneElement	Postoperative Diagnosis 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	Postoperative Diagnosis 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: 10218-6
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	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:procedure_description_section	SC	1..1	BackboneElement	Procedure Description 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		1..1	string	title
code	S	1..1	CodeableConcept	Procedure Description 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: 29554-3
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:operative_note_surgical_procedure_section	SC	0..1	BackboneElement	Operative Note Surgical Procedure 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	Operative Note Surgical Procedure 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: 10223-6
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	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:operative_note_fluids_section	SC	0..1	BackboneElement	Operative Note Fluids 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	Operative Note Fluids 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: 10216-0
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: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	SC	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:planned_procedure_section	SC	0..1	BackboneElement	Planned Procedure 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	Planned Procedure 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: 59772-4
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:planned_procedure_entry	SC	0..*	Reference(ServiceRequest)	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:procedure_disposition_section	SC	0..1	BackboneElement	Procedure Disposition 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	Procedure Disposition 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: 59775-7
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:procedure_indications_section	SC	0..1	BackboneElement	Procedure Indications 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	Procedure Indications 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: 59768-2
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.
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:procedure_implants_section	SC	0..1	BackboneElement	Procedure Implants 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	Procedure Implants 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: 59771-6
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	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:surgical_drains_section	SC	0..1	BackboneElement	Surgical Drains 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	Surgical Drains 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: 11537-8
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	required	SurgicalOperationNoteDocumentTypeCode http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:legal_attester.mode	required	Fixed Value: legal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:professional_attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:personal_attester.mode	required	Fixed Value: personal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:anesthesia_section.code	example	Pattern: LOINC Code 59774-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:anesthesia_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:anesthesia_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:anesthesia_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:complications_section.code	example	Pattern: LOINC Code 55109-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:complications_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:complications_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:complications_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:preoperative_diagnosis_section.code	example	Pattern: LOINC Code 10219-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:preoperative_diagnosis_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:preoperative_diagnosis_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:preoperative_diagnosis_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code	example	Pattern: LOINC Code 59770-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_findings_section.code	example	Pattern: LOINC Code 59776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_findings_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_findings_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_findings_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_specimens_taken_section.code	example	Pattern: LOINC Code 59773-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_specimens_taken_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_specimens_taken_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_specimens_taken_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:postoperative_diagnosis_section.code	example	Pattern: LOINC Code 10218-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:postoperative_diagnosis_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:postoperative_diagnosis_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:postoperative_diagnosis_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_description_section.code	example	Pattern: LOINC Code 29554-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_description_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_description_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_description_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.code	example	Pattern: LOINC Code 10223-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:operative_note_fluids_section.code	example	Pattern: LOINC Code 10216-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_fluids_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:operative_note_fluids_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:operative_note_fluids_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:plan_of_treatment_section.code	example	Pattern: LOINC Code 18776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:plan_of_treatment_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:plan_of_treatment_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:plan_of_treatment_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:planned_procedure_section.code	example	Pattern: LOINC Code 59772-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:planned_procedure_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:planned_procedure_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:planned_procedure_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_disposition_section.code	example	Pattern: LOINC Code 59775-7 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_disposition_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_disposition_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_disposition_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_indications_section.code	example	Pattern: LOINC Code 59768-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_indications_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_indications_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_indications_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_implants_section.code	example	Pattern: LOINC Code 59771-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_implants_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_implants_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_implants_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:surgical_drains_section.code	example	Pattern: LOINC Code 11537-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:surgical_drains_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:surgical_drains_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:surgical_drains_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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: 32 elements(24 nested mandatory elements)
Must-Support: 71 elements

Structures

This structure refers to these other structures:

• US Core Medication Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication)
• US Core MedicationRequest Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest)
• US Core Procedure Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure)
• US Core Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
• US Core Goal Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.section
• The element 1 is sliced based on the value of Composition.section.entry

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 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
language	S	1..1	code	language Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
versionNumber		0..*	string	Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
version_number_extension	S	0..1	integer	Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
performer_extension	S	0..*	Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)	performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
authorization_extension	S	0..*	Reference(Consent)	authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
order_extension	S	0..*	Reference(ServiceRequest)	authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	1..1	Identifier	identifier ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	type Binding: SurgicalOperationNoteDocumentTypeCode (required) ele-1: All FHIR elements must have a @value or children
subject	SΣ	0..1	Reference(US Core Patient Profile | Group)	Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Context of the Composition ele-1: All FHIR elements must have a @value or children
date	SΣ	1..1	dateTime	date ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children
title	SΣ	1..1	string	Document Title ele-1: All FHIR elements must have a @value or children
Slices for attester		0..*	BackboneElement	Attests to accuracy of composition Slice: Unordered, Open by value:mode ele-1: All FHIR elements must have a @value or children
attester:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children
attester:legal_attester	S	0..1	BackboneElement	attester ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: legal
party	S	1..1	Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)	party ele-1: All FHIR elements must have a @value or children
attester:professional_attester	S	0..*	BackboneElement	attester ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: professional
party	S	1..1	Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)	party ele-1: All FHIR elements must have a @value or children
attester:personal_attester	S	0..*	BackboneElement	attester ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: personal
party	S	1..1	Reference(US Core Patient Profile | RelatedPerson)	party ele-1: All FHIR elements must have a @value or children
custodian	SΣ	1..1	Reference(US Core Organization Profile)	custodian ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
section:anesthesia_section	SC	1..1	BackboneElement	Anesthesia 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Anesthesia Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59774-0
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:anesthesia_entry	SC	0..*	Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:complications_section	SC	1..1	BackboneElement	Complications 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Complications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 55109-3
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:complications_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:preoperative_diagnosis_section	SC	1..1	BackboneElement	Preoperative Diagnosis 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Preoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10219-4
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:preoperative_diagnosis_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:procedure_estimated_blood_loss_section	SC	1..1	BackboneElement	Procedure Estimated Blood Loss 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Estimated Blood Loss Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59770-8
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:procedure_findings_section	SC	1..1	BackboneElement	Procedure Findings 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59776-5
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:procedure_findings_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:procedure_specimens_taken_section	SC	1..1	BackboneElement	Procedure Specimens Taken 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Specimens Taken Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59773-2
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:postoperative_diagnosis_section	SC	1..1	BackboneElement	Postoperative Diagnosis 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Postoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10218-6
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:procedure_description_section	SC	1..1	BackboneElement	Procedure Description 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title		1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Description Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29554-3
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:operative_note_surgical_procedure_section	SC	0..1	BackboneElement	Operative Note Surgical Procedure 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Operative Note Surgical Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10223-6
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:operative_note_fluids_section	SC	0..1	BackboneElement	Operative Note Fluids 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10216-0
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
Slices for entry	SC	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children
section:planned_procedure_section	SC	0..1	BackboneElement	Planned Procedure 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Planned Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59772-4
text	SC	1..1	Narrative	text ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:planned_procedure_entry	SC	0..*	Reference(ServiceRequest)	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children
section:procedure_disposition_section	SC	0..1	BackboneElement	Procedure Disposition 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Disposition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59775-7
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:procedure_indications_section	SC	0..1	BackboneElement	Procedure Indications 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Indications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59768-2
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
Slices for entry	C	0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children
entry:problem_entry	SC	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:procedure_implants_section	SC	0..1	BackboneElement	Procedure Implants 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Procedure Implants Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 59771-6
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
section:surgical_drains_section	SC	0..1	BackboneElement	Surgical Drains 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	1..1	string	title ele-1: All FHIR elements must have a @value or children
code	S	1..1	CodeableConcept	Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11537-8
text	SC	1..1	Narrative	This section contains only human readable content ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	required	SurgicalOperationNoteDocumentTypeCode http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 from this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:legal_attester.mode	required	Fixed Value: legal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:professional_attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:personal_attester.mode	required	Fixed Value: personal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.section:anesthesia_section.code	example	Pattern: LOINC Code 59774-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:complications_section.code	example	Pattern: LOINC Code 55109-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:preoperative_diagnosis_section.code	example	Pattern: LOINC Code 10219-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code	example	Pattern: LOINC Code 59770-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_findings_section.code	example	Pattern: LOINC Code 59776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_specimens_taken_section.code	example	Pattern: LOINC Code 59773-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:postoperative_diagnosis_section.code	example	Pattern: LOINC Code 10218-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_description_section.code	example	Pattern: LOINC Code 29554-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.code	example	Pattern: LOINC Code 10223-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_fluids_section.code	example	Pattern: LOINC Code 10216-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:plan_of_treatment_section.code	example	Pattern: LOINC Code 18776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:planned_procedure_section.code	example	Pattern: LOINC Code 59772-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_disposition_section.code	example	Pattern: LOINC Code 59775-7 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_indications_section.code	example	Pattern: LOINC Code 59768-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_implants_section.code	example	Pattern: LOINC Code 59771-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:surgical_drains_section.code	example	Pattern: LOINC Code 11537-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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()

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	S	1..1	CodeableConcept	type Binding: SurgicalOperationNoteDocumentTypeCode (required)
Slices for section		0..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code
section:anesthesia_section	S	1..1	BackboneElement	Anesthesia Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Anesthesia 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: 59774-0
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:anesthesia_entry	S	0..*	Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)	A reference to data that supports this section
section:complications_section	S	1..1	BackboneElement	Complications Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Complications 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: 55109-3
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:complications_entry	S	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section
section:preoperative_diagnosis_section	S	1..1	BackboneElement	Preoperative Diagnosis Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Preoperative Diagnosis 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: 10219-4
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:preoperative_diagnosis_entry	S	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section
section:procedure_estimated_blood_loss_section	S	1..1	BackboneElement	Procedure Estimated Blood Loss Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Estimated Blood Loss 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: 59770-8
text	S	1..1	Narrative	This section contains only human readable content
section:procedure_findings_section	S	1..1	BackboneElement	Procedure Findings Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure 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: 59776-5
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:procedure_findings_entry	S	0..*	Reference(US Core Condition Profile)	A reference to data that supports this section
section:procedure_specimens_taken_section	S	1..1	BackboneElement	Procedure Specimens Taken Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Specimens Taken 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: 59773-2
text	S	1..1	Narrative	This section contains only human readable content
section:postoperative_diagnosis_section	S	1..1	BackboneElement	Postoperative Diagnosis Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Postoperative Diagnosis 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: 10218-6
text	S	1..1	Narrative	This section contains only human readable content
section:procedure_description_section	S	1..1	BackboneElement	Procedure Description Section
title		1..1	string	title
code	S	1..1	CodeableConcept	Procedure Description 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: 29554-3
text	S	1..1	Narrative	This section contains only human readable content
section:operative_note_surgical_procedure_section	S	0..1	BackboneElement	Operative Note Surgical Procedure Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Operative Note Surgical Procedure 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: 10223-6
text	S	1..1	Narrative	This section contains only human readable content
section:operative_note_fluids_section	S	0..1	BackboneElement	Operative Note Fluids Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Operative Note Fluids 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: 10216-0
text	S	1..1	Narrative	This section contains only human readable content
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	S	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:planned_procedure_section	S	0..1	BackboneElement	Planned Procedure Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Planned Procedure 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: 59772-4
text	S	1..1	Narrative	text
Slices for entry		0..*	Reference(Resource)	entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry	S	0..*	Reference(ServiceRequest)	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:procedure_disposition_section	S	0..1	BackboneElement	Procedure Disposition Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Disposition 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: 59775-7
text	S	1..1	Narrative	This section contains only human readable content
section:procedure_indications_section	S	0..1	BackboneElement	Procedure Indications Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Indications 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: 59768-2
text	S	1..1	Narrative	This section contains only human readable content
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:procedure_implants_section	S	0..1	BackboneElement	Procedure Implants Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Procedure Implants 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: 59771-6
text	S	1..1	Narrative	This section contains only human readable content
section:surgical_drains_section	S	0..1	BackboneElement	Surgical Drains Section
title	S	1..1	string	title
code	S	1..1	CodeableConcept	Surgical Drains 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: 11537-8
text	S	1..1	Narrative	This section contains only human readable content
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	required	SurgicalOperationNoteDocumentTypeCode http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 from this IG

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. Additional Bindings Purpose AllLanguages Max Binding
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	type Binding: SurgicalOperationNoteDocumentTypeCode (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:anesthesia_section	SC	1..1	BackboneElement	Anesthesia 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	Anesthesia 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: 59774-0
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:anesthesia_entry	SC	0..*	Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | 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:complications_section	SC	1..1	BackboneElement	Complications 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	Complications 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: 55109-3
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:complications_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:preoperative_diagnosis_section	SC	1..1	BackboneElement	Preoperative Diagnosis 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	Preoperative Diagnosis 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: 10219-4
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:preoperative_diagnosis_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:procedure_estimated_blood_loss_section	SC	1..1	BackboneElement	Procedure Estimated Blood Loss 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	Procedure Estimated Blood Loss 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: 59770-8
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:procedure_findings_section	SC	1..1	BackboneElement	Procedure Findings 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	Procedure 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: 59776-5
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:procedure_findings_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:procedure_specimens_taken_section	SC	1..1	BackboneElement	Procedure Specimens Taken 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	Procedure Specimens Taken 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: 59773-2
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:postoperative_diagnosis_section	SC	1..1	BackboneElement	Postoperative Diagnosis 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	Postoperative Diagnosis 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: 10218-6
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	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:procedure_description_section	SC	1..1	BackboneElement	Procedure Description 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		1..1	string	title
code	S	1..1	CodeableConcept	Procedure Description 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: 29554-3
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:operative_note_surgical_procedure_section	SC	0..1	BackboneElement	Operative Note Surgical Procedure 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	Operative Note Surgical Procedure 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: 10223-6
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	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:operative_note_fluids_section	SC	0..1	BackboneElement	Operative Note Fluids 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	Operative Note Fluids 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: 10216-0
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: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	SC	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:planned_procedure_section	SC	0..1	BackboneElement	Planned Procedure 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	Planned Procedure 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: 59772-4
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:planned_procedure_entry	SC	0..*	Reference(ServiceRequest)	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:procedure_disposition_section	SC	0..1	BackboneElement	Procedure Disposition 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	Procedure Disposition 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: 59775-7
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:procedure_indications_section	SC	0..1	BackboneElement	Procedure Indications 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	Procedure Indications 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: 59768-2
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.
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:procedure_implants_section	SC	0..1	BackboneElement	Procedure Implants 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	Procedure Implants 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: 59771-6
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	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:surgical_drains_section	SC	0..1	BackboneElement	Surgical Drains 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	Surgical Drains 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: 11537-8
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	required	SurgicalOperationNoteDocumentTypeCode http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:legal_attester.mode	required	Fixed Value: legal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:professional_attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.attester:personal_attester.mode	required	Fixed Value: personal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:anesthesia_section.code	example	Pattern: LOINC Code 59774-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:anesthesia_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:anesthesia_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:anesthesia_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:complications_section.code	example	Pattern: LOINC Code 55109-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:complications_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:complications_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:complications_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:preoperative_diagnosis_section.code	example	Pattern: LOINC Code 10219-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:preoperative_diagnosis_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:preoperative_diagnosis_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:preoperative_diagnosis_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code	example	Pattern: LOINC Code 59770-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_findings_section.code	example	Pattern: LOINC Code 59776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_findings_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_findings_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_findings_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_specimens_taken_section.code	example	Pattern: LOINC Code 59773-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_specimens_taken_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_specimens_taken_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_specimens_taken_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:postoperative_diagnosis_section.code	example	Pattern: LOINC Code 10218-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:postoperative_diagnosis_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:postoperative_diagnosis_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:postoperative_diagnosis_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_description_section.code	example	Pattern: LOINC Code 29554-3 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_description_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_description_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_description_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.code	example	Pattern: LOINC Code 10223-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:operative_note_fluids_section.code	example	Pattern: LOINC Code 10216-0 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:operative_note_fluids_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:operative_note_fluids_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:operative_note_fluids_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:plan_of_treatment_section.code	example	Pattern: LOINC Code 18776-5 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:plan_of_treatment_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:plan_of_treatment_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:plan_of_treatment_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:planned_procedure_section.code	example	Pattern: LOINC Code 59772-4 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:planned_procedure_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:planned_procedure_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:planned_procedure_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_disposition_section.code	example	Pattern: LOINC Code 59775-7 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_disposition_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_disposition_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_disposition_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_indications_section.code	example	Pattern: LOINC Code 59768-2 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_indications_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_indications_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_indications_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:procedure_implants_section.code	example	Pattern: LOINC Code 59771-6 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:procedure_implants_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:procedure_implants_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:procedure_implants_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:surgical_drains_section.code	example	Pattern: LOINC Code 11537-8 http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:surgical_drains_section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:surgical_drains_section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:surgical_drains_section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_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: 32 elements(24 nested mandatory elements)
Must-Support: 71 elements

Structures

This structure refers to these other structures:

• US Core Medication Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication)
• US Core MedicationRequest Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest)
• US Core Procedure Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure)
• US Core Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
• US Core Goal Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.section
• The element 1 is sliced based on the value of Composition.section.entry