Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

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

Resource Profile: Anesthesia Section

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.25 Version: 2.2
Active as of 2022-05-13 Computable Name: AnesthesiaSection
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.25:2014-06-09

The Anesthesia Section records the type of anesthesia (e.g., general or local) and may state the actual agent used. This may be a subsection of the Procedure Description Section. The full details of anesthesia are usually found in a separate Anesthesia Note.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (2 nested mandatory elements)

Structures

This structure refers to these other structures:

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.entry is sliced based on the values of profile:procedure, profile:substanceAdministration

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.25
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 59774-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..*Element
..... procedure 1..1ProcedureActivityProcedure
.... entry:medication 0..*Element
..... substanceAdministration 1..1MedicationActivity

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.25
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 59774-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I0..*ElementSlice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:procedure I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedure
.... entry:medication I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration I1..1MedicationActivity
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (2 nested mandatory elements)

Structures

This structure refers to these other structures:

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.entry is sliced based on the values of profile:procedure, profile:substanceAdministration

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.25
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 59774-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..*Element
..... procedure 1..1ProcedureActivityProcedure
.... entry:medication 0..*Element
..... substanceAdministration 1..1MedicationActivity

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.25
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 59774-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I0..*ElementSlice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:procedure I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedure
.... entry:medication I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration I1..1MedicationActivity
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
only-one-statementerrorSection.entrySHALL 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
only-one-statementerrorSection.entry:procedureSHALL 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
only-one-statementerrorSection.entry:medicationSHALL 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
1098-30800warningSection.entry:medication.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
: