Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot United States of America flag

Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: Anesthesia Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AnesthesiaSection Version: 4.0.0-ballot
Draft as of 2024-12-19 Computable Name: AnesthesiaSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.25:2014-06-09

The Anesthesia Section records the type of anesthesia (e.g., general or local) and may state the actual agent used. This may be a subsection of the Procedure Description Section. The full details of anesthesia are usually found in a separate Anesthesia Note.

Usage:

Formal Views of Template Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.25
..... @extension 1..1 st Required Pattern: 2014-06-09
... code 1..1 CE Procedure anesthesia Narrative
.... @code 1..1 cs Required Pattern: 59774-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..* Entry
..... procedure 1..1 ProcedureActivityProcedure Base for all types and resources
.... entry:medication 0..* Entry
..... substanceAdministration 1..1 MedicationActivity Base for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.25
..... @extension 1..1 st Required Pattern: 2014-06-09
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Procedure anesthesia Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59774-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure C 1..1 ProcedureActivityProcedure Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
active-high-ts-after-document: If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
should-performer: SHOULD contain performer
should-author: SHOULD contain author
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:medication 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration C 1..1 MedicationActivity Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
should-routeCode: SHOULD contain routeCode
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-author: SHOULD contain author
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:medication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medication.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
II-1errorSection.typeId, Section.entry:procedure.typeId, Section.entry:medication.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
active-high-ts-after-documenterrorSection.entry:procedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
dose-unit-or-admin-uniterrorSection.entry:medication.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
should-authorwarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain author
: author.exists()
should-performerwarningSection.entry:procedure.procedureSHOULD contain performer
: performer.exists()
should-routeCodewarningSection.entry:medication.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-targetSiteCodewarningSection.entry:procedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.25
..... @extension 1..1 st Required Pattern: 2014-06-09
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Procedure anesthesia Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59774-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure C 1..1 ProcedureActivityProcedure Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
active-high-ts-after-document: If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
should-performer: SHOULD contain performer
should-author: SHOULD contain author
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:medication 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration C 1..1 MedicationActivity Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
should-routeCode: SHOULD contain routeCode
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-author: SHOULD contain author
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:medication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medication.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
II-1errorSection.typeId, Section.entry:procedure.typeId, Section.entry:medication.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
active-high-ts-after-documenterrorSection.entry:procedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
dose-unit-or-admin-uniterrorSection.entry:medication.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
should-authorwarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain author
: author.exists()
should-performerwarningSection.entry:procedure.procedureSHOULD contain performer
: performer.exists()
should-routeCodewarningSection.entry:medication.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-targetSiteCodewarningSection.entry:procedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements(2 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Section.templateId
  • The element 2 is sliced based on the values of Section.entry

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.25
..... @extension 1..1 st Required Pattern: 2014-06-09
... code 1..1 CE Procedure anesthesia Narrative
.... @code 1..1 cs Required Pattern: 59774-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..* Entry
..... procedure 1..1 ProcedureActivityProcedure Base for all types and resources
.... entry:medication 0..* Entry
..... substanceAdministration 1..1 MedicationActivity Base for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.25
..... @extension 1..1 st Required Pattern: 2014-06-09
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Procedure anesthesia Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59774-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure C 1..1 ProcedureActivityProcedure Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
active-high-ts-after-document: If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
should-performer: SHOULD contain performer
should-author: SHOULD contain author
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:medication 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration C 1..1 MedicationActivity Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
should-routeCode: SHOULD contain routeCode
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-author: SHOULD contain author
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:medication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medication.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
II-1errorSection.typeId, Section.entry:procedure.typeId, Section.entry:medication.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
active-high-ts-after-documenterrorSection.entry:procedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
dose-unit-or-admin-uniterrorSection.entry:medication.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
should-authorwarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain author
: author.exists()
should-performerwarningSection.entry:procedure.procedureSHOULD contain performer
: performer.exists()
should-routeCodewarningSection.entry:medication.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-targetSiteCodewarningSection.entry:procedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.25
..... @extension 1..1 st Required Pattern: 2014-06-09
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Procedure anesthesia Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59774-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:substanceAdministration
.... entry:procedure 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure C 1..1 ProcedureActivityProcedure Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
active-high-ts-after-document: If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
should-performer: SHOULD contain performer
should-author: SHOULD contain author
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:medication 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration C 1..1 MedicationActivity Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
should-routeCode: SHOULD contain routeCode
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-author: SHOULD contain author
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:procedure.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:medication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:medication.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medication.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
II-1errorSection.typeId, Section.entry:procedure.typeId, Section.entry:medication.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
active-high-ts-after-documenterrorSection.entry:procedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
dose-unit-or-admin-uniterrorSection.entry:medication.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
should-authorwarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain author
: author.exists()
should-performerwarningSection.entry:procedure.procedureSHOULD contain performer
: performer.exists()
should-routeCodewarningSection.entry:medication.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-targetSiteCodewarningSection.entry:procedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:procedure.procedure, Section.entry:medication.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements(2 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Section.templateId
  • The element 2 is sliced based on the values of Section.entry

 

Other representations of profile: CSV, Excel