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: Reason for Visit Section

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12 | Version: 2.2
Active as of 2022-05-13 | Computable Name: ReasonforVisitSection
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.2.12

This section records the patients reason for the patient’s visit (as documented by the provider). Local policy determines whether Reason for Visit and Chief Complaint are in separate or combined sections.

Usage:

- Use this Resource Profile: History and Physical, Consultation Note, Procedure Note, Discharge Summary

### 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: 7 elements

Slices

This structure defines the following Slices:

- The element Section.templateId is sliced based on the value of value:root

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: 2.16.840.1.113883.10.20.22.2.12
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 29299-5
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

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
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: 2.16.840.1.113883.10.20.22.2.12
extension |  | 0..1 | string |
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 29299-5
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 |
entry | I | 0..* | Element |
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 |
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: 7 elements

Slices

This structure defines the following Slices:

- The element Section.templateId is sliced based on the value of value:root

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: 2.16.840.1.113883.10.20.22.2.12
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 29299-5
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

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
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: 2.16.840.1.113883.10.20.22.2.12
extension |  | 0..1 | string |
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 29299-5
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 |
entry | I | 0..* | Element |
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 |
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 |