Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.16 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: HospitalDischargeStudiesSummarySection | |||
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.2.16 |
This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record 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 when a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram.
Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy.
Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
Summary
Mandatory: 7 elements
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.16 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 11493-4 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ED | ||
text | 1..1 | xhtml | ||
Documentation for this format |
This structure is derived from CDAR2.Section
Summary
Mandatory: 7 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.16 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 11493-4 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ED | ||
text | 1..1 | xhtml | ||
Documentation for this format |
Snapshot View
Other representations of profile: CSV, Excel, Schematron
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 |
Section.subject.typeCode | required | Fixed Value: SBJ |
Section.subject.contextControlCode | required | Fixed Value: OP |
Section.subject.awarenessCode | extensible | TargetAwareness |
Section.informant.typeCode | required | Fixed Value: INF |
Section.informant.contextControlCode | required | Fixed Value: OP |
Id | Grade | Path | Details | Requirements |
only-one-statement | error | Section.entry | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |