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: Referral Note

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

A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.

Examples of referral situations are:

  • When a patient is referred from a family physician to a cardiologist for cardiac evaluation.
  • When patient is sent by a cardiologist to an emergency department for angina.
  • When a patient is referred by a nurse practitioner to an audiologist for hearing screening.
  • When a patient is referred by a hospitalist to social services.

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: ReferralDocumentType (required)
... Slices for section 0..*BackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
.... section:allergies_and_intolerances_section S1..1BackboneElementAllergies and Intolerances 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: 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:medications_section S1..1BackboneElementMedications 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: 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:problem_section S1..1BackboneElementProblem Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptProblem list
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: 11450-4
..... text S1..1Narrativetext
..... 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:reason_for_referral_section S1..1BackboneElementReason for Referral 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: 42349-1
..... text S1..1NarrativeThis section contains only human readable content
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:reason_for_referral_entry S0..*Reference(ServiceRequest)A reference to data that supports this section
.... section:functional_status_section S0..1BackboneElementFunctional Status 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: 47420-5
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:functional_status_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:mental_status_section S0..1BackboneElementMental Status 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: 10190-7
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:mental_status_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:nutrition_section S0..1BackboneElementNutrition Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptDiet and nutrition
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: 61144-2
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:nutrition_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:results_section S0..1BackboneElementResults Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptRelevant diagnostic tests and laboratory data
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: 30954-2
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:results_entry S0..*Reference(US Core Laboratory Result Observation Profile)A reference to data that supports this section
.... 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 1..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:advance_directives_section S0..1BackboneElementAdvance Directives Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptAdvance directives
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: 42348-3
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry S0..*Reference(Consent)A reference to data that supports this section
.... section:assessment_section S0..1BackboneElementAssessment 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: 51848-0
..... text S1..1NarrativeThis section contains only human readable content
.... section:family_history_section S0..1BackboneElementFamily History Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of family member diseases
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:general_status_section S0..1BackboneElementGeneral Status 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: 10210-3
..... text S1..1NarrativeThis section contains only human readable content
.... section:past_medical_history_section S0..1BackboneElementPast Medical History Section
..... title 1..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:immunizations_section S0..1BackboneElementImmunizations Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHistory of immunization
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: 11369-6
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:immunizations_entry S0..*Reference(US Core Immunization Profile)A reference to data that supports this section
.... section:medical_equipment_section S0..1BackboneElementMedical Equipment Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptMedical equipment
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: 46264-8
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry S0..*Reference(Device | US Core Procedure Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:physical_exam_section S0..1BackboneElementPhysical Exam 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: 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: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:review_of_systems_section S0..1BackboneElementReview of Systems 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: 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
.... section:vital_signs_section S0..1BackboneElementVital Signs Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptVital signs
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: 8716-3
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:vital_signs_entry S0..*Reference(Vital Signs Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:goals_section S0..1BackboneElementGoals Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptGoals
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: 61146-7
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:goals_entry S0..*Reference(US Core Goal Profile)entry
.... section:health_concerns_section S0..1BackboneElementHealth Concerns Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHealth concerns section code
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: 75310-3
..... text S1..1Narrativetext
..... Slices for entry 0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:health_concerns_entry S0..*Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typerequiredReferralDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3
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: ReferralDocumentType (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:allergies_and_intolerances_section SC1..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..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: 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:medications_section SC1..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..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: 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:problem_section SC1..1BackboneElementProblem 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..1CodeableConceptProblem list
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: 11450-4
..... text SC1..1Narrativetext
..... 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:reason_for_referral_section SC1..1BackboneElementReason for Referral 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: 42349-1
..... text SC1..1NarrativeThis section contains only human readable content
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:reason_for_referral_entry SC0..*Reference(ServiceRequest)A reference to data that supports this section
.... section:functional_status_section SC0..1BackboneElementFunctional Status Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!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: 47420-5
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:functional_status_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:mental_status_section SC0..1BackboneElementMental Status Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!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: 10190-7
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:mental_status_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:nutrition_section SC0..1BackboneElementNutrition 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..1CodeableConceptDiet and nutrition
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: 61144-2
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:nutrition_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:results_section SC0..1BackboneElementResults 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..1CodeableConceptRelevant diagnostic tests and laboratory data
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: 30954-2
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:results_entry SC0..*Reference(US Core Laboratory Result Observation Profile)A reference to data that supports this section
.... 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 C1..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:advance_directives_section SC0..1BackboneElementAdvance Directives 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..1CodeableConceptAdvance directives
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: 42348-3
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry SC0..*Reference(Consent)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..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: 51848-0
..... 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..1CodeableConceptHistory of family member diseases
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:general_status_section SC0..1BackboneElementGeneral Status Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!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: 10210-3
..... text SC1..1NarrativeThis section contains only human readable content
.... 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 1..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:immunizations_section SC0..1BackboneElementImmunizations 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 immunization
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: 11369-6
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:immunizations_entry SC0..*Reference(US Core Immunization Profile)A reference to data that supports this section
.... section:medical_equipment_section SC0..1BackboneElementMedical Equipment 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 equipment
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: 46264-8
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry SC0..*Reference(Device | US Core Procedure Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... 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..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: 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:procedures_section SC0..1BackboneElementProcedures 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 procedures
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: 47519-4
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:procedures_entry SC0..*Reference(US Core Procedure Profile)A reference to data that supports this section
.... section:review_of_systems_section SC0..1BackboneElementReview of Systems Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!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: 10187-3
..... text SC1..1NarrativeThis section contains only human readable content
.... section:social_history_section SC0..1BackboneElementSocial 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..1CodeableConceptSocial 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: 29762-2
..... text SC1..1Narrativetext
..... Slices for entry C0..*Reference(Resource)entry
Slice: Unordered, Open by profile:resolve()
...... entry:social_history_entry SC0..*Reference(US Core Smoking Status Observation Profile)Smoking status
.... section:vital_signs_section SC0..1BackboneElementVital Signs Section
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.....