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: Hospital Discharge Diagnosis

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.33 | Version: 2.2
Active as of 2022-05-13 | Computable Name: HospitalDischargeDiagnosis
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2015-08-01

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization. It requires at least one Problem Observation entry.

Usage:

- Use this Resource Profile: Discharge Diagnosis Section

### 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.Act

Summary

Mandatory: 11 elements

Structures

This structure refers to these other structures:

- Problem Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.4)

Slices

This structure defines the following Slices:

- The element Act.templateId is sliced based on the values of value:extension, value:root
- The element Act.entryRelationship is sliced based on the value of profile:observation

This structure is derived from CDAR2.Act

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act |
classCode |  | 1..1 | code | Required Pattern: ACT
moodCode |  | 1..1 | code | Required Pattern: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:extension, value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.33
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CD |
code |  | 1..1 | string | Required Pattern: 11535-2
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
Slices for entryRelationship |  | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SUBJ
observation |  | 1..1 | ProblemObservation |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act |
classCode |  | 1..1 | code | Required Pattern: ACT
moodCode |  | 1..1 | code | Required Pattern: EVN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:extension, 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: 2.16.840.1.113883.10.20.22.4.33
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id |  | 0..* | II |
code |  | 1..1 | CD | Binding: v3 Code System ActCode (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 11535-2
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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
negationInd |  | 0..1 | boolean |
text |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
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 |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
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 |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | I | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
(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 |
entryRelationship:problemObservation | I | 1..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SUBJ
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
observation |  | 1..1 | ProblemObservation |
reference |  | 0..* | Element |
typeCode |  | 1..1 | code |
seperatableInd |  | 0..1 | BL |
externalAct |  | 0..1 | ExternalAct |
externalObservation |  | 0..1 | ExternalObservation |
externalProcedure |  | 0..1 | ExternalProcedure |
externalDocument |  | 0..1 | ExternalDocument |
precondition |  | 0..* | Precondition |
Documentation for this format

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

This structure is derived from CDAR2.Act

Summary

Mandatory: 11 elements

Structures

This structure refers to these other structures:

- Problem Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.4)

Slices

This structure defines the following Slices:

- The element Act.templateId is sliced based on the values of value:extension, value:root
- The element Act.entryRelationship is sliced based on the value of profile:observation

Differential View

This structure is derived from CDAR2.Act

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act |
classCode |  | 1..1 | code | Required Pattern: ACT
moodCode |  | 1..1 | code | Required Pattern: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:extension, value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.33
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CD |
code |  | 1..1 | string | Required Pattern: 11535-2
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
Slices for entryRelationship |  | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:problemObservation |  | 1..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SUBJ
observation |  | 1..1 | ProblemObservation |
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Act |  | 1..1 | CDAR2.Act |
classCode |  | 1..1 | code | Required Pattern: ACT
moodCode |  | 1..1 | code | Required Pattern: EVN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:extension, 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: 2.16.840.1.113883.10.20.22.4.33
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id |  | 0..* | II |
code |  | 1..1 | CD | Binding: v3 Code System ActCode (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 11535-2
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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
negationInd |  | 0..1 | boolean |
text |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
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 |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
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 |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | I | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
(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 |
entryRelationship:problemObservation | I | 1..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SUBJ
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
observation |  | 1..1 | ProblemObservation |
reference |  | 0..* | Element |
typeCode |  | 1..1 | code |
seperatableInd |  | 0..1 | BL |
externalAct |  | 0..1 | ExternalAct |
externalObservation |  | 0..1 | ExternalObservation |
externalProcedure |  | 0..1 | ExternalProcedure |
externalDocument |  | 0..1 | ExternalDocument |
precondition |  | 0..* | Precondition |
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Act.templateId:primary.nullFlavor | required | NullFlavor
Act.code | extensible | ActCode
Act.code.nullFlavor | required | NullFlavor
Act.statusCode | required | ActStatus
Act.priorityCode | extensible | ActPriority
Act.languageCode | required | HumanLanguage
Act.subject.typeCode | required | Fixed Value: SBJ
Act.subject.contextControlCode | required | Fixed Value: OP
Act.subject.awarenessCode | extensible | TargetAwareness
Act.informant.typeCode | required | Fixed Value: INF
Act.informant.contextControlCode | required | Fixed Value: OP

#### Constraints

Id | Grade | Path | Details | Requirements
act-er-1 | error | Act.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
act-er-1 | error | Act.entryRelationship:problemObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |