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: Procedure Note

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

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe 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..1CodeableConceptProcedure Note
Binding: ProcedureNoteDocumentTypeCodes (required)
... event S1..*BackboneElementserviceEvent
.... period 1..1Periodperiod
..... start 1..1dateTimestart
..... end 1..1dateTimeend
... Slices for section 0..*BackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
.... 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:procedure_description_section S1..1BackboneElementProcedure Description Section
..... title S1..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:procedure_indications_section S1..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
.... section:postprocedure_diagnosis_section S1..1BackboneElementPostprocedure Diagnosis Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPostprocedure 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: 59769-0
..... text S1..1Narrativetext
..... Slices for entry S0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:postprocedure_diagnosis_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:allergies_and_intolerances_section S0..1BackboneElementAllergies and Intolerances Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptAllergies and/or adverse reactions
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergies_and_intolerances_entry S0..*Reference(US Core AllergyIntolerance Profile)A reference to data that supports this section
.... section:assessment_section S0..1BackboneElementAssessment Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptAssessments
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51848-0
..... text S1..1NarrativeThis section contains only human readable content
.... section:assessment_and_plan_section S0..1BackboneElementAssessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
..... title S1..1stringtitle
..... code S1..1CodeableConceptAssessment and plan
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51847-2
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:assessment_and_plan_entry S0..*Reference(US Core Condition Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:anesthesia_section S0..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:chief_complaint_and_reason_for_visit_section S0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46239-0
..... text S1..1NarrativeThis section contains only human readable content
.... section:chief_complaint_section S0..1BackboneElementChief Complaint Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10154-3
..... text S1..1NarrativeThis section contains only human readable content
.... section:family_history_section S0..1BackboneElementFamily History Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10157-6
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:family_history_entry S0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:past_medical_history_section S0..1BackboneElementPast Medical History Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11348-0
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:past_medical_history_entry S0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:history_of_present_illness_section S0..1BackboneElementHistory of Present Illness Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
..... text S1..1NarrativeThis section contains only human readable content
.... section:medical_history_section S0..1BackboneElementMedical (General) History Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptMedical (general) history
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11329-0
..... text S1..1NarrativeThis section contains only human readable content
.... section:medications_section S0..1BackboneElementMedications Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of medication use
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medications_entry S0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)A reference to data that supports this section
.... section:medications_administered_section S0..1BackboneElementMedications Administered Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptMedications administered
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: 29549-3
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medications_administered_entry S0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)A reference to data that supports this section
.... section:physical_exam_section S0..1BackboneElementPhysical Exam Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPhysical findings
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29545-1
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:physical_exam_entry S0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section: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 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 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
.... 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_estimated_blood_loss_section S0..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 S0..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..1NarrativeThis section contains only human readable content
.... 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:procedure_specimens_taken_section S0..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:procedures_section S0..1BackboneElementProcedures Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of procedures
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47519-4
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:procedures_entry S0..*Reference(US Core Procedure Profile)A reference to data that supports this section
.... section:reason_for_visit_section S0..1BackboneElementReason for Visit Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
..... text S1..1NarrativeThis section contains only human readable content
.... section:review_of_systems_section S0..1BackboneElementReview of Systems Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptReview of systems
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10187-3
..... text S1..1NarrativeThis section contains only human readable content
.... section:social_history_section S0..1BackboneElementSocial History Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptSocial history
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29762-2
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:social_history_entry S0..*Reference(US Core Smoking Status Observation Profile)Smoking status

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typerequiredProcedureNoteDocumentTypeCodes
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1
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..1CodeableConceptProcedure Note
Binding: ProcedureNoteDocumentTypeCodes (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
... event SΣ1..*BackboneElementserviceEvent
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... period Σ1..1Periodperiod
..... start ΣC1..1dateTimestart
..... end ΣC1..1dateTimeend
... 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: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: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 S1..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:procedure_indications_section SC1..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
.... section:postprocedure_diagnosis_section SC1..1BackboneElementPostprocedure 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..1CodeableConceptPostprocedure 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: 59769-0
..... text SC1..1Narrativetext
..... Slices for entry SC0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:postprocedure_diagnosis_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:allergies_and_intolerances_section SC0..1BackboneElementAllergies and Intolerances Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptAllergies and/or adverse reactions
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51848-0
..... text SC1..1NarrativeThis section contains only human readable content
.... section:assessment_and_plan_section SC0..1BackboneElementAssessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptAssessment and plan
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51847-2
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:assessment_and_plan_entry SC0..*Reference(US Core Condition Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:anesthesia_section SC0..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:chief_complaint_and_reason_for_visit_section SC0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46239-0
..... text SC1..1NarrativeThis section contains only human readable content
.... section:chief_complaint_section SC0..1BackboneElementChief Complaint Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10154-3
..... text SC1..1NarrativeThis section contains only human readable content
.... section:family_history_section SC0..1BackboneElementFamily History Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10157-6
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:family_history_entry SC0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:past_medical_history_section SC0..1BackboneElementPast Medical History Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11348-0
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:past_medical_history_entry SC0..*Reference(US Core Condition Profile)A reference to data that supports this section
.... section:history_of_present_illness_section SC0..1BackboneElementHistory of Present Illness Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptcode
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
..... text SC1..1NarrativeThis section contains only human readable content
.... section:medical_history_section SC0..1BackboneElementMedical (General) History Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptMedical (general) history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11329-0
..... text SC1..1NarrativeThis section contains only human readable content
.... section:medications_section SC0..1BackboneElementMedications Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of medication use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medications_entry SC0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)A reference to data that supports this section
.... section:medications_administered_section SC0..1BackboneElementMedications Administered 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..1CodeableConceptMedications administered
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: 29549-3
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medications_administered_entry SC0..*Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)A reference to data that supports this section
.... section:physical_exam_section SC0..1BackboneElementPhysical Exam Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPhysical findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29545-1
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:physical_exam_entry SC0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section: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 C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section: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
.... 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_estimated_blood_loss_section SC0..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 SC0..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..1NarrativeThis section contains only human readable content
.... 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
.....