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
Mappings for the Referral-Note resource profile.
| ReferralNote |
| Composition | Entity. Role, or Act, Document[classCode="DOC" and moodCode="EVN" and isNormalAct()] |
| text | Act.text? |
| contained | N/A |
| modifierExtension | N/A |
| identifier | Document.id / Document.setId |
| status | interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete" |
| type | ./code |
| category | .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code |
| subject | .participation[typeCode="SBJ"].role[typeCode="PAT"] |
| encounter | unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct]) |
| date | .effectiveTime[type="TS"] |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| title | ./title |
| attester | .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| mode | unique(./modeCode) |
| time | ./time[type="TS" and isNormalDatatype()] |
| party | ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] |
| attester (legal_attester) | .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| mode | unique(./modeCode) |
| time | ./time[type="TS" and isNormalDatatype()] |
| party | ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] |
| attester (professional_attester) | .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| mode | unique(./modeCode) |
| time | ./time[type="TS" and isNormalDatatype()] |
| party | ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] |
| attester (personal_attester) | .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| mode | unique(./modeCode) |
| time | ./time[type="TS" and isNormalDatatype()] |
| party | ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] |
| custodian | .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"] |
| relatesTo | .outboundRelationship |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| code | .outboundRelationship.typeCode |
| target[x] | .target[classCode="DOC", moodCode="EVN"].id |
| event | outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT'] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| code | .code |
| period | .effectiveTime |
| detail | .outboundRelationship[typeCode="SUBJ"].target |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (allergies_and_intolerances_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (allergies_and_intolerances_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (medications_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (medications_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (problem_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (problem_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (reason_for_referral_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (reason_for_referral_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (functional_status_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (functional_status_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (mental_status_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (mental_status_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (nutrition_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (nutrition_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (plan_of_treatment_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (sliceEntry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (results_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (results_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (assessment_and_plan_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (assessment_and_plan_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (advance_directives_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (advance_directive_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (assessment_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (family_history_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (family_history_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (general_status_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (past_medical_history_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (past_medical_history_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (history_of_present_illness_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (immunizations_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (immunizations_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (medical_equipment_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (medical_equipment_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (physical_exam_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (physical_exam_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (procedures_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (procedures_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (review_of_systems_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (social_history_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (social_history_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (vital_signs_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (vital_signs_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (goals_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (goals_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| section (health_concerns_section) | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| id | n/a |
| extension | n/a |
| modifierExtension | N/A |
| title | ./title |
| code | ./code |
| author | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| text | .text |
| mode | .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value |
| orderedBy | .outboundRelationship[typeCode=COMP].sequenceNumber > 1 |
| entry | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| entry (health_concerns_entry) | .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] |
| emptyReason | .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] |
| section | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] |
| ReferralNote |
| Composition | ClinicalDocument |
| identifier | .setId |
| status | n/a |
| type | .code |
| category | n/a |
| subject | .recordTarget |
| encounter | .componentOf.encompassingEncounter |
| date | .effectiveTime |
| author | .author.assignedAuthor |
| title | .title |
| attester | .authenticator/.legalAuthenticator |
| mode | implied by .authenticator/.legalAuthenticator |
| time | .authenticator.time |
| party | .authenticator.assignedEnttty |
| attester (legal_attester) | .authenticator/.legalAuthenticator |
| mode | implied by .authenticator/.legalAuthenticator |
| time | .authenticator.time |
| party | .authenticator.assignedEnttty |
| attester (professional_attester) | .authenticator/.legalAuthenticator |
| mode | implied by .authenticator/.legalAuthenticator |
| time | .authenticator.time |
| party | .authenticator.assignedEnttty |
| attester (personal_attester) | .authenticator/.legalAuthenticator |
| mode | implied by .authenticator/.legalAuthenticator |
| time | .authenticator.time |
| party | .authenticator.assignedEnttty |
| custodian | .custodian.assignedCustodian |
| relatesTo | .relatedDocument |
| code | .relatedDocument.typeCode |
| target[x] | .relatedDocument.id |
| event | .documentationOf.serviceEvent |
| code | .code |
| period | .effectiveTime |
| detail | n/a |
| section | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (allergies_and_intolerances_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (allergies_and_intolerances_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (medications_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (medications_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (problem_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (problem_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (reason_for_referral_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (reason_for_referral_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (functional_status_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (functional_status_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (mental_status_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (mental_status_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (nutrition_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (nutrition_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (plan_of_treatment_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (sliceEntry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (results_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (results_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (assessment_and_plan_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (assessment_and_plan_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (advance_directives_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (advance_directive_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (assessment_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (family_history_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (family_history_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (general_status_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (past_medical_history_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (past_medical_history_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (history_of_present_illness_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (immunizations_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (immunizations_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (medical_equipment_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (medical_equipment_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (physical_exam_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (physical_exam_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (procedures_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (procedures_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (review_of_systems_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (social_history_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (social_history_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (vital_signs_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (vital_signs_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (goals_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (goals_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
| section (health_concerns_section) | .component.structuredBody.component.section |
| title | .title |
| code | .code |
| author | .author.assignedAuthor |
| focus | .subject? (CDA did not differentiate between subject and focus) |
| text | .text |
| mode | n/a |
| orderedBy | n/a |
| entry | .entry |
| entry (health_concerns_entry) | .entry |
| emptyReason | n/a |
| section | .component.section |
|
Propose a change