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: Discharge Diagnosis Section

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.24 | Version: 2.2
Active as of 2022-05-13 | Computable Name: DischargeDiagnosisSection
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.24:2015-08-01

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization. This section includes an optional entry to record patient diagnoses specific to this visit. Problems that need ongoing tracking should also be included in the Problem Section.

Usage:

- Use this Resource Profile: Transfer Summary, 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: 11 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

- Hospital Discharge Diagnosis (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.33)

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.code.translation is sliced based on the values of value:code, value:codeSystem

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: 2.16.840.1.113883.10.20.22.2.24
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 11535-2
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
code |  | 1..1 | string | Required Pattern: 78375-3
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
entry |  | 0..1 | Element |
act |  | 1..1 | HospitalDischargeDiagnosis |
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: 2.16.840.1.113883.10.20.22.2.24
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: 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 |
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 78375-3
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 |
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..1 | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act |  | 1..1 | HospitalDischargeDiagnosis |
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: 11 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

- Hospital Discharge Diagnosis (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.33)

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.code.translation is sliced based on the values of value:code, value:codeSystem

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: 2.16.840.1.113883.10.20.22.2.24
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 11535-2
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
code |  | 1..1 | string | Required Pattern: 78375-3
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
entry |  | 0..1 | Element |
act |  | 1..1 | HospitalDischargeDiagnosis |
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: 2.16.840.1.113883.10.20.22.2.24
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: 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 |
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem
translation:translation1 |  | 1..1 | CD |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 78375-3
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 |
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..1 | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act |  | 1..1 | HospitalDischargeDiagnosis |
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.code.translation:translation1.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 |