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/2.16.840.1.113883.10.20.6.1.2 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: FindingsSectionDIR | |||
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.6.1.2 |
The Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
Summary
Mandatory: 2 elements
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | I | 1..1 | CDAR2.Section | 81-8532: This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.6.1.2 | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | I | 1..1 | CDAR2.Section | 81-8532: This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). |
text | 0..1 | xhtml | ||
Documentation for this format |
This structure is derived from CDAR2.Section
Summary
Mandatory: 2 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | I | 1..1 | CDAR2.Section | 81-8532: This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.6.1.2 | |
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.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 |
81-8532 | warning | Section | This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). : | |
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 |