Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Discharge Diagnosis Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/DischargeDiagnosisSection Version: 2.1
Draft as of 2023-09-29 Computable Name: DischargeDiagnosisSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.24:2015-08-01

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization. This section includes an optional entry to record patient diagnoses specific to this visit. Problems that need ongoing tracking should also be included in the Problem Section.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 11535-2
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CD
...... code 1..1csRequired Pattern: 78375-3
...... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CD
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @ID 0..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CD
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... qualifier 0..*CR
...... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... entry 0..1Entry
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
.... @contextConductionInd 0..1blFixed Value: true
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources
.... encounter 0..1Encounter
.... observation 0..1Observation
.... observationMedia 0..1ObservationMedia
.... organizer 0..1Organizer
.... procedure 0..1Procedure
.... regionOfInterest 0..1RegionOfInterest
.... substanceAdministration 0..1SubstanceAdministration
.... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.code.translation:translation1.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry.nullFlavorrequiredNullFlavor
Section.entry.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Section

Summary

Mandatory: 13 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.code.translation is sliced based on the values of value:code, value:codeSystem

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 11535-2
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CD
...... code 1..1csRequired Pattern: 78375-3
...... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CD
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @ID 0..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CD
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... qualifier 0..*CR
...... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... entry 0..1Entry
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
.... @contextConductionInd 0..1blFixed Value: true
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources
.... encounter 0..1Encounter
.... observation 0..1Observation
.... observationMedia 0..1ObservationMedia
.... organizer 0..1Organizer
.... procedure 0..1Procedure
.... regionOfInterest 0..1RegionOfInterest
.... substanceAdministration 0..1SubstanceAdministration
.... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.code.translation:translation1.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry.nullFlavorrequiredNullFlavor
Section.entry.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Section

Summary

Mandatory: 13 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.code.translation is sliced based on the values of value:code, value:codeSystem

 

Other representations of profile: CSV, Excel