Consolidated CDA Release 2.2
2.2 - CI Build

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: Preoperative Diagnosis Section (V3)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.34 | Version: 2.2
Active as of 2022-05-13 | Computable Name: PreoperativeDiagnosisSection
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.34:2015-08-01

The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon’s opinion, the diagnosis that will be confirmed during surgery.

Usage:

- Use this Resource Profile: Operative Note

### Formal Views of Profile Content

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

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

- Preoperative Diagnosis (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.65)

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 value of value:act

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, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.34
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 10219-4
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
Slices for entry |  | 0..* | Element | Slice: Unordered, Open by value:act
entry:preopDiagnosis |  | 0..1 | Element |
act |  | 1..1 | PreoperativeDiagnosis |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCSECT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.34
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 10219-4
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ED |
text | S | 1..1 | xhtml |
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
awarenessCode |  | 0..1 | CE | Binding: TargetAwareness (extensible)
relatedSubject |  | 1..1 | RelatedSubject |
author |  | 0..* | Author |
informant |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 0..1 | RelatedEntity |
Slices for entry | I | 0..* | Element | Slice: Unordered, Open by value:act
entry:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
(Choice of one) |  | 1..1 |  |
observation |  | 0..1 | Observation |
regionOfInterest |  | 0..1 | RegionOfInterest |
observationMedia |  | 0..1 | ObservationMedia |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
procedure |  | 0..1 | Procedure |
encounter |  | 0..1 | Encounter |
organizer |  | 0..1 | Organizer |
act |  | 0..1 | Act |
entry:preopDiagnosis | I | 0..1 | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act |  | 1..1 | PreoperativeDiagnosis |
component |  | 0..* | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
text |  | 1..1 | xhtml |
Documentation for this format

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

- Preoperative Diagnosis (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.65)

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 value of value:act

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, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.34
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 10219-4
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
Slices for entry |  | 0..* | Element | Slice: Unordered, Open by value:act
entry:preopDiagnosis |  | 0..1 | Element |
act |  | 1..1 | PreoperativeDiagnosis |
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCSECT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.34
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 10219-4
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ED |
text | S | 1..1 | xhtml |
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
awarenessCode |  | 0..1 | CE | Binding: TargetAwareness (extensible)
relatedSubject |  | 1..1 | RelatedSubject |
author |  | 0..* | Author |
informant |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 0..1 | RelatedEntity |
Slices for entry | I | 0..* | Element | Slice: Unordered, Open by value:act
entry:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
(Choice of one) |  | 1..1 |  |
observation |  | 0..1 | Observation |
regionOfInterest |  | 0..1 | RegionOfInterest |
observationMedia |  | 0..1 | ObservationMedia |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
procedure |  | 0..1 | Procedure |
encounter |  | 0..1 | Encounter |
organizer |  | 0..1 | Organizer |
act |  | 0..1 | Act |
entry:preopDiagnosis | I | 0..1 | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act |  | 1..1 | PreoperativeDiagnosis |
component |  | 0..* | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### 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
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

#### Constraints

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 |
only-one-statement | error | Section.entry:preopDiagnosis | 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 |