Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernsSection | Version: 4.0.0-ballot | |||
| Draft as of 2024-11-21 | Computable Name: HealthConcernsSection | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.58:2015-08-01 | ||||
This section contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management. A Health Concern is a health related matter that is of interest, importance or worry to someone, who may be the patient, patient's family or patient's health care provider. Health concerns are derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). Health concerns can be medical, surgical, nursing, allied health or patient-reported concerns.
Problem Concerns are a subset of Health Concerns that have risen to the level of importance that they typically would belong on a classic "Problem List", such as "Diabetes Mellitus" or "Family History of Melanoma" or "Tobacco abuse". These are of broad interest to multiple members of the care team. Examples of other Health Concerns that might not typically be considered a Problem Concern include "Risk of Hyperkalemia" for a patient taking an ACE-inhibitor medication, or "Transportation difficulties" for someone who doesn't drive and has trouble getting to appointments, or "Under-insured" for someone who doesn't have sufficient insurance to properly cover their medical needs such as medications. These are typically most important to just a limited number of care team members.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Section |
C | 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) should-health-status-obs: SHOULD contain Health Status Observation shall-health-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act |
 @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI | |
  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: 2.16.840.1.113883.10.20.22.2.58 | |
  @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | Health concerns Document | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
 @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
 Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation, profile:act | |
 entry:healthStatus |
0..* | Entry | ||
  observation |
1..1 | HealthStatusObservation | Base for all types and resources | |
| entry:healthConcern |
0..* | Entry | If section/@nullFlavor is not present: | |
| act |
1..1 | HealthConcernAct | Base for all types and resources | |
| entry:riskConcern |
0..* | Entry | ||
| act |
1..1 | RiskConcernAct | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| shall-health-concern-act | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct')).exists() | |
| should-health-status-obs | warning | Section | SHOULD contain Health Status Observation : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation')) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section |
C | 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) should-health-status-obs: SHOULD contain Health Status Observation shall-health-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act |
 @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required) | |
| 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: 2.16.840.1.113883.10.20.22.2.58 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | Health concerns Document Binding: DocumentSectionType (example) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation, profile:act | |
| entry:healthStatus |
0..* | Entry | ||
| observation |
C | 1..1 | HealthStatusObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entry:healthConcern |
0..* | Entry | If section/@nullFlavor is not present: | |
| act |
C | 1..1 | HealthConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| entry:riskConcern |
0..* | Entry | ||
| act |
C | 1..1 | RiskConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| shall-health-concern-act | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct')).exists() | |
| should-author | warning | Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain author : author.exists() | |
| should-health-status-obs | warning | Section | SHOULD contain Health Status Observation : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation')) | |
| should-text-ref-value | warning | Section.entry:healthStatus.observation, Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section |
C | 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) should-health-status-obs: SHOULD contain Health Status Observation shall-health-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act |
| @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| 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: 2.16.840.1.113883.10.20.22.2.58 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| @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 | Health concerns Document Binding: DocumentSectionType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @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 | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation, profile:act | |
| entry:healthStatus |
0..* | Entry | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
0..1 | II | ||
 @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 |
C | 1..1 | HealthStatusObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entry:healthConcern |
0..* | Entry | If section/@nullFlavor is not present: | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | HealthConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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 | ||
| entry:riskConcern |
0..* | Entry | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | RiskConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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 | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:healthStatus.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthStatus.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthStatus.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:healthConcern.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthConcern.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthConcern.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:riskConcern.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:riskConcern.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:riskConcern.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| shall-health-concern-act | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct')).exists() | |
| should-author | warning | Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain author : author.exists() | |
| should-health-status-obs | warning | Section | SHOULD contain Health Status Observation : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation')) | |
| should-text-ref-value | warning | Section.entry:healthStatus.observation, Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
This structure is derived from Section
Summary
Mandatory: 9 elements(3 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section |
C | 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) should-health-status-obs: SHOULD contain Health Status Observation shall-health-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act |
| @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI | |
| 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: 2.16.840.1.113883.10.20.22.2.58 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | Health concerns Document | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation, profile:act | |
| entry:healthStatus |
0..* | Entry | ||
| observation |
1..1 | HealthStatusObservation | Base for all types and resources | |
| entry:healthConcern |
0..* | Entry | If section/@nullFlavor is not present: | |
| act |
1..1 | HealthConcernAct | Base for all types and resources | |
| entry:riskConcern |
0..* | Entry | ||
| act |
1..1 | RiskConcernAct | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| shall-health-concern-act | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct')).exists() | |
| should-health-status-obs | warning | Section | SHOULD contain Health Status Observation : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation')) |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section |
C | 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) should-health-status-obs: SHOULD contain Health Status Observation shall-health-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act |
| @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required) | |
| 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: 2.16.840.1.113883.10.20.22.2.58 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | Health concerns Document Binding: DocumentSectionType (example) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation, profile:act | |
| entry:healthStatus |
0..* | Entry | ||
| observation |
C | 1..1 | HealthStatusObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entry:healthConcern |
0..* | Entry | If section/@nullFlavor is not present: | |
| act |
C | 1..1 | HealthConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| entry:riskConcern |
0..* | Entry | ||
| act |
C | 1..1 | RiskConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| shall-health-concern-act | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct')).exists() | |
| should-author | warning | Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain author : author.exists() | |
| should-health-status-obs | warning | Section | SHOULD contain Health Status Observation : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation')) | |
| should-text-ref-value | warning | Section.entry:healthStatus.observation, Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section |
C | 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) should-health-status-obs: SHOULD contain Health Status Observation shall-health-concern-act: If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act |
| @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| 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: 2.16.840.1.113883.10.20.22.2.58 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| @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 | Health concerns Document Binding: DocumentSectionType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @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 | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation, profile:act | |
| entry:healthStatus |
0..* | Entry | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | HealthStatusObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entry:healthConcern |
0..* | Entry | If section/@nullFlavor is not present: | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | HealthConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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 | ||
| entry:riskConcern |
0..* | Entry | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | RiskConcernAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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 | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:healthStatus.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthStatus.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthStatus.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:healthConcern.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthConcern.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:healthConcern.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:riskConcern.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:riskConcern.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:riskConcern.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| shall-health-concern-act | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Health Concern Act : nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct')).exists() | |
| should-author | warning | Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain author : author.exists() | |
| should-health-status-obs | warning | Section | SHOULD contain Health Status Observation : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusObservation')) | |
| should-text-ref-value | warning | Section.entry:healthStatus.observation, Section.entry:healthConcern.act, Section.entry:riskConcern.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
This structure is derived from Section
Summary
Mandatory: 9 elements(3 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-11-21
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