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: Problem Section (entries required)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.5.1 | Version: 2.2
Active as of 2022-05-13 | Computable Name: ProblemSectionEntriesRequired
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.5.1:2015-08-01

This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Overall health status may be represented in this section.

Usage:

- Use this Resource Profile: Transfer Summary, Referral Note, Continuity of Care Document (CCD), Consultation 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 ProblemSectionEntriesOptional

Summary

Mandatory: 9 elements

Slices

This structure defines the following Slices:

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

This structure is derived from ProblemSectionEntriesOptional

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | ProblemSectionEntriesOptional |
nullFlavor |  | 0..1 | code | Required Pattern: NI
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:extension, value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.5.1
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 11450-4
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
entry |  | 1..* | Element | If section/@nullFlavor is not present:
entry:act |  | 0..* | Element |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | ProblemSectionEntriesOptional |
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required) Required Pattern: NI
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: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: 2.16.840.1.113883.10.20.22.2.5.1
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: 11450-4
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 | 1..* | Element | If section/@nullFlavor is not present: Slice: Unordered, Open by exists:*
entry:act | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act |  | 1..1 | ProblemConcernAct |
entry:observation | I | 0..1 | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | HealthStatusObservation |
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 | ProblemSectionEntriesOptional |
text |  | 1..1 | xhtml |
Documentation for this format

This structure is derived from ProblemSectionEntriesOptional

Summary

Mandatory: 9 elements

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from ProblemSectionEntriesOptional

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | ProblemSectionEntriesOptional |
nullFlavor |  | 0..1 | code | Required Pattern: NI
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:extension, value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.5.1
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 11450-4
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
entry |  | 1..* | Element | If section/@nullFlavor is not present:
entry:act |  | 0..* | Element |
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | ProblemSectionEntriesOptional |
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required) Required Pattern: NI
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: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: 2.16.840.1.113883.10.20.22.2.5.1
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: 11450-4
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 | 1..* | Element | If section/@nullFlavor is not present: Slice: Unordered, Open by exists:*
entry:act | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act |  | 1..1 | ProblemConcernAct |
entry:observation | I | 0..1 | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | HealthStatusObservation |
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 | Pattern: NI
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:act | 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:observation | 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 |