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: General Status Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/GeneralStatusSection Version: 4.0.0-ballot
Draft as of 2024-12-19 Computable Name: GeneralStatusSection
Other Identifiers: OID:2.16.840.1.113883.10.20.2.5

The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.

Usage:

Formal Views of Template Content

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

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: 2.16.840.1.113883.10.20.2.5
... @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 Physical findings of General status Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 10210-3
.... @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
... entry 0..* Entry
... 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.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
II-1errorSection.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()

 

Other representations of profile: CSV, Excel