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

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

Resource Profile: Operative Note

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

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.

2024 Publication of C-CDA ↔ FHIR US Core Mapping

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

Usage:

Formal Views of Profile Content

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

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... type S1..1CodeableConcepttype
Binding: SurgicalOperationNoteDocumentTypeCode (required)
... Slices for section 0..*BackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
.... section:anesthesia_section S1..1BackboneElementAnesthesia Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptAnesthesia
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59774-0
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:anesthesia_entry S0..*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 S1..1BackboneElementComplications Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptComplications
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 55109-3
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:complications_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:preoperative_diagnosis_section S1..1BackboneElementPreoperative Diagnosis Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPreoperative Diagnosis
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10219-4
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:preoperative_diagnosis_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:procedure_estimated_blood_loss_section S1..1BackboneElementProcedure Estimated Blood Loss Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Estimated Blood Loss
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59770-8
..... text S1..1NarrativeThis section contains only human readable content
.... section:procedure_findings_section S1..1BackboneElementProcedure Findings Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Findings
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59776-5
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:procedure_findings_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:procedure_specimens_taken_section S1..1BackboneElementProcedure Specimens Taken Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Specimens Taken
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59773-2
..... text S1..1NarrativeThis section contains only human readable content
.... section:postoperative_diagnosis_section S1..1BackboneElementPostoperative Diagnosis Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPostoperative Diagnosis
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10218-6
..... text S1..1NarrativeThis section contains only human readable content
.... section:procedure_description_section S1..1BackboneElementProcedure Description Section
..... title 1..1stringtitle
..... code S1..1CodeableConceptProcedure Description
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29554-3
..... text S1..1NarrativeThis section contains only human readable content
.... section:operative_note_surgical_procedure_section S0..1BackboneElementOperative Note Surgical Procedure Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptOperative Note Surgical Procedure
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10223-6
..... text S1..1NarrativeThis section contains only human readable content
.... section:operative_note_fluids_section S0..1BackboneElementOperative Note Fluids Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptOperative Note Fluids
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10216-0
..... text S1..1NarrativeThis section contains only human readable content
.... section:plan_of_treatment_section S0..1BackboneElementPlan of Treatment Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPlan of Treatment
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
..... text S1..1Narrativetext
..... Slices for entry S0..*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 S0..1BackboneElementPlanned Procedure Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPlanned Procedure
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59772-4
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:planned_procedure_entry S0..*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 S0..1BackboneElementProcedure Disposition Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Disposition
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59775-7
..... text S1..1NarrativeThis section contains only human readable content
.... section:procedure_indications_section S0..1BackboneElementProcedure Indications Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Indications
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59768-2
..... text S1..1NarrativeThis section contains only human readable content
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:procedure_implants_section S0..1BackboneElementProcedure Implants Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Implants
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59771-6
..... text S1..1NarrativeThis section contains only human readable content
.... section:surgical_drains_section S0..1BackboneElementSurgical Drains Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptSurgical Drains
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11537-8
..... text S1..1NarrativeThis section contains only human readable content

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typerequiredSurgicalOperationNoteDocumentTypeCode
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language S1..1codelanguage
Binding: CommonLanguages (preferred): A human language.

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

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

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


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


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


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


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59774-0
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:anesthesia_entry SC0..*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 SC1..1BackboneElementComplications Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptComplications
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 55109-3
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:complications_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:preoperative_diagnosis_section SC1..1BackboneElementPreoperative 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPreoperative Diagnosis
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10219-4
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:preoperative_diagnosis_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:procedure_estimated_blood_loss_section SC1..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Estimated Blood Loss
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59770-8
..... text SC1..1NarrativeThis section contains only human readable content
.... section:procedure_findings_section SC1..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59776-5
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:procedure_findings_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:procedure_specimens_taken_section SC1..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Specimens Taken
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59773-2
..... text SC1..1NarrativeThis section contains only human readable content
.... section:postoperative_diagnosis_section SC1..1BackboneElementPostoperative 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPostoperative Diagnosis
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10218-6
..... text SC1..1NarrativeThis section contains only human readable content
.... section:procedure_description_section SC1..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1stringtitle
..... code S1..1CodeableConceptProcedure Description
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29554-3
..... text SC1..1NarrativeThis section contains only human readable content
.... section:operative_note_surgical_procedure_section SC0..1BackboneElementOperative 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptOperative Note Surgical Procedure
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10223-6
..... text SC1..1NarrativeThis section contains only human readable content
.... section:operative_note_fluids_section SC0..1BackboneElementOperative 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptOperative Note Fluids
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10216-0
..... text SC1..1NarrativeThis section contains only human readable content
.... section:plan_of_treatment_section SC0..1BackboneElementPlan of Treatment Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPlan of Treatment
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
..... text SC1..1Narrativetext
..... Slices for entry SC0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:planned_procedure_section SC0..1BackboneElementPlanned 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPlanned Procedure
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59772-4
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:planned_procedure_entry SC0..*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 SC0..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Disposition
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59775-7
..... text SC1..1NarrativeThis section contains only human readable content
.... section:procedure_indications_section SC0..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Indications
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59768-2
..... text SC1..1NarrativeThis section contains only human readable content
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:procedure_implants_section SC0..1BackboneElementProcedure 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptProcedure Implants
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59771-6
..... text SC1..1NarrativeThis section contains only human readable content
.... section:surgical_drains_section SC0..1BackboneElementSurgical 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
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptSurgical Drains
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11537-8
..... text SC1..1NarrativeThis section contains only human readable content

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typerequiredSurgicalOperationNoteDocumentTypeCode
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.section:anesthesia_section.codeexamplePattern: LOINC code 59774-0
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:complications_section.codeexamplePattern: LOINC code 55109-3
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:preoperative_diagnosis_section.codeexamplePattern: LOINC code 10219-4
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.codeexamplePattern: LOINC code 59770-8
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_findings_section.codeexamplePattern: LOINC code 59776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_specimens_taken_section.codeexamplePattern: LOINC code 59773-2
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:postoperative_diagnosis_section.codeexamplePattern: LOINC code 10218-6
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_description_section.codeexamplePattern: LOINC code 29554-3
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.codeexamplePattern: LOINC code 10223-6
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:operative_note_fluids_section.codeexamplePattern: LOINC code 10216-0
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:plan_of_treatment_section.codeexamplePattern: LOINC code 18776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:planned_procedure_section.codeexamplePattern: LOINC code 59772-4
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_disposition_section.codeexamplePattern: LOINC code 59775-7
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_indications_section.codeexamplePattern: LOINC code 59768-2
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:procedure_implants_section.codeexamplePattern: LOINC code 59771-6
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:surgical_drains_section.codeexamplePattern: LOINC code 11537-8
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.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_sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.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_sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language S1..1codelanguage
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... versionNumber 0..*stringVersion-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... version_number_extension S0..1integerExtension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
... data_enterer_extension S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
... informant_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
... information_recipient_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
... participant_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
... performer_extension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
... authorization_extension S0..*Reference(Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
... order_extension S0..*Reference(ServiceRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ1..1Identifieridentifier
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConcepttype
Binding: SurgicalOperationNoteDocumentTypeCode (required)
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


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

..... time 0..1dateTimeWhen the composition was attested
..... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
.... attester:legal_attester S0..1BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


Fixed Value: legal
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:professional_attester S0..*BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


Fixed Value: professional
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:personal_attester S0..*BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.


Fixed Value: personal
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Patient Profile | RelatedPerson)party
... custodian SΣ1..1Reference(US Core Organization Profile)custodian
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(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 Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... Slices for section C0..*BackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification 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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C0..*Reference(Resource)A reference to data that supports this section
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:anesthesia_section SC1..1BackboneElementAnesthesia 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptAnesthesia
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 59774-0
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SC1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:anesthesia_entry SC0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)A reference to data that supports this section
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:complications_section SC1..1BackboneElementComplications 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptComplications
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 55109-3
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SC1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:complications_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:preoperative_diagnosis_section SC1..1BackboneElementPreoperative 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPreoperative Diagnosis
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10219-4
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SC1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes