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: Hospital Discharge Diagnosis

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HospitalDischargeDiagnosis Version: 2.1
Draft as of 2023-09-29 Computable Name: HospitalDischargeDiagnosis
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2015-08-01

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization. It requires at least one Problem Observation entry.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
... classCode 1..1csFixed Value: ACT
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.33
..... extension 1..1stRequired Pattern: 2015-08-01
.... code 1..1csRequired Pattern: 11535-2
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*EntryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.33
..... @extension 1..1stRequired Pattern: 2015-08-01
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.codeextensibleActCode
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ

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
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.33
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (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
.... qualifier 0..*CR
.... translation 0..*CD
... @negationInd 0..1bl
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1ProblemObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.nullFlavorrequiredNullFlavor
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.statusCoderequiredActStatus
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.entryRelationship:problemObservation.nullFlavorrequiredNullFlavor
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ

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.Act

Summary

Mandatory: 9 elements
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:extension, value:root
  • The element Act.entryRelationship is sliced based on the value of profile:observation

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
... classCode 1..1csFixed Value: ACT
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.33
..... extension 1..1stRequired Pattern: 2015-08-01
.... code 1..1csRequired Pattern: 11535-2
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*EntryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.33
..... @extension 1..1stRequired Pattern: 2015-08-01
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.codeextensibleActCode
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ

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
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.33
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (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
.... qualifier 0..*CR
.... translation 0..*CD
... @negationInd 0..1bl
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1ProblemObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.nullFlavorrequiredNullFlavor
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.statusCoderequiredActStatus
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.entryRelationship:problemObservation.nullFlavorrequiredNullFlavor
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ

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.Act

Summary

Mandatory: 9 elements
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:extension, value:root
  • The element Act.entryRelationship is sliced based on the value of profile:observation

 

Other representations of profile: CSV, Excel