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: Medical (General) History Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicalGeneralHistorySection | Version: 2.1
Draft as of 2023-09-29 | Computable Name: MedicalGeneralHistorySection
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.2.39

The Medical History Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.

Usage:

- Use this Logical Model: Procedure Note

### 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.Section

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
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39
extension |  | 0..0 |  |
code |  | 1..1 | CE |
code |  | 1..1 | cs | Required Pattern: 11329-0
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text |  | 1..1 | xhtml |
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
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@code |  | 1..1 | cs | Required Pattern: 11329-0
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text | S | 1..1 | xhtml |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet
Section.code | extensible | DocumentSectionType

#### 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
--- | --- | --- | --- | ---
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
@ID |  | 0..1 | xs:ID |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root
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: 2.16.840.1.113883.10.20.22.2.39
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 11329-0
@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 |
translation |  | 0..* | CD |
title |  | 1..1 | ST |
text | S | 1..1 | xhtml |
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Subject |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
entry |  | 0..* | Entry |
component |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | Section |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Section.nullFlavor | required | NullFlavor
Section.classCode | required | Fixed Value: DOCSECT
Section.moodCode | required | Fixed Value: EVN
Section.templateId:primary.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.component.nullFlavor | required | NullFlavor

#### 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.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

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
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39
extension |  | 0..0 |  |
code |  | 1..1 | CE |
code |  | 1..1 | cs | Required Pattern: 11329-0
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text |  | 1..1 | xhtml |
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
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@code |  | 1..1 | cs | Required Pattern: 11329-0
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text | S | 1..1 | xhtml |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet
Section.code | extensible | DocumentSectionType

#### 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
--- | --- | --- | --- | ---
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
@ID |  | 0..1 | xs:ID |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root
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: 2.16.840.1.113883.10.20.22.2.39
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 11329-0
@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 |
translation |  | 0..* | CD |
title |  | 1..1 | ST |
text | S | 1..1 | xhtml |
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Subject |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
entry |  | 0..* | Entry |
component |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | Section |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Section.nullFlavor | required | NullFlavor
Section.classCode | required | Fixed Value: DOCSECT
Section.moodCode | required | Fixed Value: EVN
Section.templateId:primary.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.component.nullFlavor | required | NullFlavor

#### 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.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