Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 Ballot 1 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 5.0.0-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: Assessment and Plan Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection Version: 5.0.0-ballot
Draft as of 2025-12-12 Computable Name: AssessmentandPlanSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.9:2014-06-09

This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.

When this section.text contains extra information not contained in the discrete entries, it is helpful to wrap the text of this section in a Note Activity to support ingestion.

See also the Assessment Section: templateId 2.16.840.1.113883.10.20.22.2.8 and Plan of Treatment Section: templateId 2.16.840.1.113883.10.20.22.2.10:2014-06-09

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Optional Entries: NoteActivity, PlannedProcedure

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 4.0.0:

  • New Content

    • Formal Views of Template Content

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

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: no-a-p
    ... 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: 2.16.840.1.113883.10.20.22.2.9
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... code 1..1 CE Evaluation + Plan note
    .... @code 1..1 cs Required Pattern: 51847-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST Label of a section
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:act
    .... entry:plannedProcedure 0..* Entry
    ..... procedure 1..1 PlannedProcedure
    .... entry:notes 0..* Entry
    ..... act 1..1 NoteActivity

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    no-a-p error Section When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: no-a-p
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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: 2.16.840.1.113883.10.20.22.2.9
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... code 1..1 CE Evaluation + Plan note
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 51847-2
    .... @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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:act
    .... entry:plannedProcedure 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 PlannedProcedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entry:notes 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 NoteActivity
    ..... 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 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... component 0..* InfrastructureRoot Used to nest a Section within a Section
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @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

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:plannedProcedure.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.entry:notes.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:plannedProcedure.typeId, Section.entry:notes.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    no-a-p error Section When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: no-a-p
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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: 2.16.840.1.113883.10.20.22.2.9
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... code 1..1 CE Evaluation + Plan note
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 51847-2
    .... @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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:act
    .... entry:plannedProcedure 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 PlannedProcedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entry:notes 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 NoteActivity
    ..... 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 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... component 0..* InfrastructureRoot Used to nest a Section within a Section
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @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

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:plannedProcedure.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.entry:notes.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:plannedProcedure.typeId, Section.entry:notes.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    no-a-p error Section When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()

    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 & Constraints    Filter: Filtersdoco
    .. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: no-a-p
    ... 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: 2.16.840.1.113883.10.20.22.2.9
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... code 1..1 CE Evaluation + Plan note
    .... @code 1..1 cs Required Pattern: 51847-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST Label of a section
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:act
    .... entry:plannedProcedure 0..* Entry
    ..... procedure 1..1 PlannedProcedure
    .... entry:notes 0..* Entry
    ..... act 1..1 NoteActivity

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    no-a-p error Section When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: no-a-p
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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: 2.16.840.1.113883.10.20.22.2.9
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... code 1..1 CE Evaluation + Plan note
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 51847-2
    .... @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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:act
    .... entry:plannedProcedure 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 PlannedProcedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entry:notes 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 NoteActivity
    ..... 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 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... component 0..* InfrastructureRoot Used to nest a Section within a Section
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @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

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:plannedProcedure.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.entry:notes.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:plannedProcedure.typeId, Section.entry:notes.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    no-a-p error Section When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: no-a-p
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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: 2.16.840.1.113883.10.20.22.2.9
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... code 1..1 CE Evaluation + Plan note
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 51847-2
    .... @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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:procedure, profile:act
    .... entry:plannedProcedure 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 PlannedProcedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entry:notes 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 NoteActivity
    ..... 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 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... component 0..* InfrastructureRoot Used to nest a Section within a Section
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @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

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:plannedProcedure.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:plannedProcedure.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.entry:notes.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:notes.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:plannedProcedure.typeId, Section.entry:notes.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    no-a-p error Section When using this section, the Assessment Section and the Plan of Treatment Section SHALL NOT be used. %resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty()

    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