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: Hospital Discharge Studies Summary Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HospitalDischargeStudiesSummarySection Version: 5.0.0-ballot
Draft as of 2025-12-09 Computable Name: HospitalDischargeStudiesSummarySection
Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.16

This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record all results for the period of time being documented.

Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.

Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as when a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram.

Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy.

Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.

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 Section XML Namespace: urn:hl7-org:v3
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root
    .... templateId:section 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.16
    ..... @extension 0..0
    ... code 1..1 CE Hospital discharge studies summary Narrative
    .... @code 1..1 cs Required Pattern: 11493-4
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST Label of a section

    doco Documentation for this format
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 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)
    ... @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: 2.16.840.1.113883.10.20.22.2.16
    ... @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 Hospital discharge studies summary Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 11493-4
    .... @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
    ... entry 0..* Entry
    ... 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 vnull
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture vnull
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 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)
    ... @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: 2.16.840.1.113883.10.20.22.2.16
    ... @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 Hospital discharge studies summary Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 11493-4
    .... @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
    ... entry 0..* Entry
    ... 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 vnull
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture vnull
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

    This structure is derived from Section

    Summary

    Mandatory: 8 elements
    Prohibited: 1 element

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of Section.templateId

    Differential View

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section Section XML Namespace: urn:hl7-org:v3
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root
    .... templateId:section 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.16
    ..... @extension 0..0
    ... code 1..1 CE Hospital discharge studies summary Narrative
    .... @code 1..1 cs Required Pattern: 11493-4
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST Label of a section

    doco Documentation for this format

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 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)
    ... @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: 2.16.840.1.113883.10.20.22.2.16
    ... @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 Hospital discharge studies summary Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 11493-4
    .... @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
    ... entry 0..* Entry
    ... 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 vnull
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture vnull
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 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)
    ... @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: 2.16.840.1.113883.10.20.22.2.16
    ... @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 Hospital discharge studies summary Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 11493-4
    .... @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
    ... entry 0..* Entry
    ... 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 vnull
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture vnull
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture vnull

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

    This structure is derived from Section

    Summary

    Mandatory: 8 elements
    Prohibited: 1 element

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of Section.templateId

     

    Other representations of profile: CSV, Excel