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: General Status Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/GeneralStatusSection Version: 2.1
Draft as of 2023-09-29 Computable Name: GeneralStatusSection
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.2.5

The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.

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 CDAR2.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
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.5
..... extension 0..0
... code 1..1CE
.... code 1..1csRequired Pattern: 10210-3
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST

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
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.5
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 10210-3
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST

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
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.5
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 10210-3
.... @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
.... 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..*Entry
... 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.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
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: 8 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the value of value:root

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.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
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.5
..... extension 0..0
... code 1..1CE
.... code 1..1csRequired Pattern: 10210-3
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST

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
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.5
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 10210-3
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST

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
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.5
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 10210-3
.... @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
.... 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..*Entry
... 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.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
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: 8 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the value of value:root

 

Other representations of profile: CSV, Excel