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: Discharge Diagnosis Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/DischargeDiagnosisSection | Version: 2.1
Draft as of 2023-09-29 | Computable Name: DischargeDiagnosisSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.24:2015-08-01

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization. This section includes an optional entry to record patient diagnoses specific to this visit. Problems that need ongoing tracking should also be included in the Problem Section.

Usage:

- Use this Logical Model: Discharge Summary and Transfer Summary

### 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, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.24
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | cs | Required Pattern: 11535-2
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for translation |  | 1..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: 78375-3
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text |  | 1..1 | xhtml |
entry |  | 0..1 | Entry |
act |  | 1..1 | HospitalDischargeDiagnosis | 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
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: 2.16.840.1.113883.10.20.22.2.24
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@code |  | 1..1 | cs | Required Pattern: 11535-2
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for translation |  | 1..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
@code |  | 1..1 | cs | Required Pattern: 78375-3
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text | S | 1..1 | xhtml |
entry |  | 0..1 | Entry |
act |  | 1..1 | HospitalDischargeDiagnosis | Base for all types and resources
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, 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: 2.16.840.1.113883.10.20.22.2.24
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 11535-2
@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 |
Slices for translation |  | 1..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 78375-3
@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 |
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..1 | Entry |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: x_ActRelationshipEntry (required)
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
act |  | 1..1 | HospitalDischargeDiagnosis | Base for all types and resources
encounter |  | 0..1 | Encounter |
observation |  | 0..1 | Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
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.code.translation:translation1.nullFlavor | required | NullFlavor
Section.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Section.entry.nullFlavor | required | NullFlavor
Section.entry.typeCode | required | XActRelationshipEntry
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: 13 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

- Hospital Discharge Diagnosis (http://hl7.org/cda/us/ccda/StructureDefinition/HospitalDischargeDiagnosis)

Slices

This structure defines the following Slices:

- The element Section.templateId is sliced based on the values of value:root, value:extension
- The element Section.code.translation is sliced based on the values of value:code, value:codeSystem

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, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.24
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | cs | Required Pattern: 11535-2
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for translation |  | 1..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: 78375-3
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text |  | 1..1 | xhtml |
entry |  | 0..1 | Entry |
act |  | 1..1 | HospitalDischargeDiagnosis | 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
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: 2.16.840.1.113883.10.20.22.2.24
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@code |  | 1..1 | cs | Required Pattern: 11535-2
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
Slices for translation |  | 1..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
@code |  | 1..1 | cs | Required Pattern: 78375-3
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ST |
text | S | 1..1 | xhtml |
entry |  | 0..1 | Entry |
act |  | 1..1 | HospitalDischargeDiagnosis | Base for all types and resources
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, 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: 2.16.840.1.113883.10.20.22.2.24
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 11535-2
@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 |
Slices for translation |  | 1..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 78375-3
@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 |
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..1 | Entry |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: x_ActRelationshipEntry (required)
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
act |  | 1..1 | HospitalDischargeDiagnosis | Base for all types and resources
encounter |  | 0..1 | Encounter |
observation |  | 0..1 | Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
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.code.translation:translation1.nullFlavor | required | NullFlavor
Section.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Section.entry.nullFlavor | required | NullFlavor
Section.entry.typeCode | required | XActRelationshipEntry
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: 13 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

- Hospital Discharge Diagnosis (http://hl7.org/cda/us/ccda/StructureDefinition/HospitalDischargeDiagnosis)

Slices

This structure defines the following Slices:

- The element Section.templateId is sliced based on the values of value:root, value:extension
- The element Section.code.translation is sliced based on the values of value:code, value:codeSystem

Other representations of profile: CSV, Excel