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
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection | Version: 2.1 | |||
Draft as of 2023-09-29 | Computable Name: ResultsSection | |||
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.3.1:2015-08-01 |
The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. These coded result observations are contained within a Results Organizer in the Results Section. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.
Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.
Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.
Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | CDAR2.Section | XML 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 | ||
nullFlavor | 0..1 | cs | Fixed Value: NI | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | 1..1 | II | ||
root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.3.1 | |
extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | cs | Required Pattern: 30954-2 | |
codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 1..* | Entry | If section/@nullFlavor is not present: Slice: Unordered, Open by value:organizer | |
entry:organizer | 1..* | Entry | ||
organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | XML 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 | |
@nullFlavor | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: NI | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.3.1 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
@code | 1..1 | cs | Required Pattern: 30954-2 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | S | 1..1 | xhtml | |
Slices for entry | 1..* | Entry | If section/@nullFlavor is not present: Slice: Unordered, Open by value:organizer | |
entry:organizer | 1..* | Entry | ||
organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | Fixed Value: NI |
Section.code | extensible | DocumentSectionType |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | Fixed Value: NI |
Section.classCode | required | Fixed Value: DOCSECT |
Section.moodCode | required | Fixed Value: EVN |
Section.templateId:secondary.nullFlavor | required | NullFlavor |
Section.code | extensible | DocumentSectionType |
Section.code.nullFlavor | required | NullFlavor |
Section.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Section.entry:organizer.nullFlavor | required | NullFlavor |
Section.entry:organizer.typeCode | required | XActRelationshipEntry |
Section.component.nullFlavor | required | NullFlavor |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Section
Summary
Mandatory: 12 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | CDAR2.Section | XML 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 | ||
nullFlavor | 0..1 | cs | Fixed Value: NI | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | 1..1 | II | ||
root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.3.1 | |
extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | cs | Required Pattern: 30954-2 | |
codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 1..* | Entry | If section/@nullFlavor is not present: Slice: Unordered, Open by value:organizer | |
entry:organizer | 1..* | Entry | ||
organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | XML 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 | |
@nullFlavor | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: NI | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.3.1 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
@code | 1..1 | cs | Required Pattern: 30954-2 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | S | 1..1 | xhtml | |
Slices for entry | 1..* | Entry | If section/@nullFlavor is not present: Slice: Unordered, Open by value:organizer | |
entry:organizer | 1..* | Entry | ||
organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | Fixed Value: NI |
Section.code | extensible | DocumentSectionType |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | Fixed Value: NI |
Section.classCode | required | Fixed Value: DOCSECT |
Section.moodCode | required | Fixed Value: EVN |
Section.templateId:secondary.nullFlavor | required | NullFlavor |
Section.code | extensible | DocumentSectionType |
Section.code.nullFlavor | required | NullFlavor |
Section.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Section.entry:organizer.nullFlavor | required | NullFlavor |
Section.entry:organizer.typeCode | required | XActRelationshipEntry |
Section.component.nullFlavor | required | NullFlavor |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Section
Summary
Mandatory: 12 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: