Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build

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: Preoperative Diagnosis

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis | Version: 2.1
Draft as of 2023-09-29 | Computable Name: PreoperativeDiagnosis
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.65:2015-08-01

This template represents the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.

Usage:

- Use this Logical Model: Health Concern Act, Preoperative Diagnosis Section and Risk Concern Act

### Formal Views of Profile Content

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

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from CDAR2.Act

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  |  | CDAR2.Act | XML 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..1 | cs | Fixed Value: ACT
moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.65
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: 10219-4
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: SUBJ
observation |  | 1..1 | ProblemObservation | Base for all types and resources
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act | XML 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..1 | cs | Fixed Value: ACT
@moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.65
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CD | Binding: v3 Code System ActCode (extensible)
@code |  | 1..1 | cs | Required Pattern: 10219-4
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
observation |  | 1..1 | ProblemObservation | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Act.code | extensible | ActCode
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ

#### Constraints

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()) |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act | XML 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..1 | cs | Binding: NullFlavor (required)
@classCode |  | 1..1 | cs | Fixed Value: ACT
@moodCode |  | 1..1 | cs | Fixed Value: EVN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.65
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 0..* | II |
code |  | 1..1 | CD | Binding: v3 Code System ActCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 10219-4
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
@negationInd |  | 0..1 | bl |
text |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | ProblemObservation | Base for all types and resources
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Act.nullFlavor | required | NullFlavor
Act.templateId:primary.nullFlavor | required | NullFlavor
Act.code | extensible | ActCode
Act.code.nullFlavor | required | NullFlavor
Act.statusCode | required | ActStatus
Act.priorityCode | extensible | ActPriority
Act.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Act.entryRelationship:problemObservation.nullFlavor | required | NullFlavor
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ

#### Constraints

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.Act

Summary

Mandatory: 9 elements
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

- Problem Observation (http://hl7.org/cda/us/ccda/StructureDefinition/ProblemObservation)

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from CDAR2.Act

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  |  | CDAR2.Act | XML 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..1 | cs | Fixed Value: ACT
moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.65
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: 10219-4
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: SUBJ
observation |  | 1..1 | ProblemObservation | Base for all types and resources
Documentation for this format

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act | XML 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..1 | cs | Fixed Value: ACT
@moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.65
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CD | Binding: v3 Code System ActCode (extensible)
@code |  | 1..1 | cs | Required Pattern: 10219-4
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
observation |  | 1..1 | ProblemObservation | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Act.code | extensible | ActCode
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ

#### Constraints

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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act | XML 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..1 | cs | Binding: NullFlavor (required)
@classCode |  | 1..1 | cs | Fixed Value: ACT
@moodCode |  | 1..1 | cs | Fixed Value: EVN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.65
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 0..* | II |
code |  | 1..1 | CD | Binding: v3 Code System ActCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 10219-4
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
@negationInd |  | 0..1 | bl |
text |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | ProblemObservation | Base for all types and resources
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Act.nullFlavor | required | NullFlavor
Act.templateId:primary.nullFlavor | required | NullFlavor
Act.code | extensible | ActCode
Act.code.nullFlavor | required | NullFlavor
Act.statusCode | required | ActStatus
Act.priorityCode | extensible | ActPriority
Act.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Act.entryRelationship:problemObservation.nullFlavor | required | NullFlavor
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ

#### Constraints

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.Act

Summary

Mandatory: 9 elements
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

- Problem Observation (http://hl7.org/cda/us/ccda/StructureDefinition/ProblemObservation)

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel