C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot
C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot
C-CDA on FHIR, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ccda-on-fhir/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header | Version: 2.0.0-ballot | |||
| Active as of 2025-02-12 | Computable Name: USRealmHeader | |||
This profile defines constraints that represent common administrative and demographic concepts for US Realm clinical documents. Further specification, such as type, are provided in document profiles that conform to this profile.
2025 Ballot of C-CDA ↔ FHIR US Core MappingThe 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  Composition |
0..* | Clinical Document | This is an abstractprofile. Childprofiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |||||
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children | ||||
| language |
S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
ele-1: All FHIR elements must have a @value or children | ||||
  Slices for extension |
Content/Rules for all slices | |||||||
   versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| version_number_extension |
S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| data_enterer_extension |
S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| informant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| information_recipient_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| performer_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| authorization_extension |
S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
 order_extension |
S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
 identifier |
SΣ | 1..1 | Identifier | identifier ele-1: All FHIR elements must have a @value or children | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children | ||||
 subject |
SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children | ||||
| encounter |
SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition ele-1: All FHIR elements must have a @value or children | ||||
| date |
SΣ | 1..1 | dateTime | date ele-1: All FHIR elements must have a @value or children | ||||
| author |
SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children | ||||
| title |
SΣ | 1..1 | string | Document Title ele-1: All FHIR elements must have a @value or children | ||||
| Slices for attester |
0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode ele-1: All FHIR elements must have a @value or children | |||||
  attester:All Slices |
Content/Rules for all slices | |||||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | |||||
| attester:legal_attester |
S | 0..1 | BackboneElement | attester ele-1: All FHIR elements must have a @value or children | ||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: legal | ||||
 party |
S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party ele-1: All FHIR elements must have a @value or children | ||||
| attester:professional_attester |
S | 0..* | BackboneElement | attester ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: professional | ||||
| party |
S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party ele-1: All FHIR elements must have a @value or children | ||||
 attester:personal_attester |
S | 0..* | BackboneElement | attester ele-1: All FHIR elements must have a @value or children | ||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: personal | ||||
| party |
S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party ele-1: All FHIR elements must have a @value or children | ||||
 custodian |
SΣ | 1..1 | Reference(US Core Organization Profile) | custodian ele-1: All FHIR elements must have a @value or children | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Cross-Group Projects. Package hl7.fhir.us.ccda#2.0.0-ballot based on FHIR 4.0.1. Generated 2025-02-12
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change
