Consolidated CDA (C-CDA)
4.0.0 - STU4 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 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: Instructions Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/InstructionsSection Version: 4.0.0
Draft as of 2025-10-02 Computable Name: InstructionsSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.45:2014-06-09

The Instructions Section records instructions given to a patient. List patient decision aids here.

Templates Used

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

Required Entries: InstructionActivity or InstructionObservation

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 3.0.0:

  • 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: shall-instruction
    ... @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: 2.16.840.1.113883.10.20.22.2.45
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... code 1..1 CE Instructions
    .... @code 1..1 cs Required Pattern: 69730-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... text 1..1 xhtml
    ... Slices for entry 0..* Entry If section/@nullFlavor is not present:
    Slice: Unordered, Open by profile:act, profile:observation
    .... entry:instructionAct 0..* Entry
    ..... act 1..1 InstructionActivity
    .... entry:instructionObservation 0..* Entry
    ..... observation 1..1 InstructionObservation

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    shall-instruction error Section If section/@nullFlavor is not present, SHALL contain at least one Instruction nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists()
    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: shall-instruction
    ... @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 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: 2.16.840.1.113883.10.20.22.2.45
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Instructions
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 69730-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry If section/@nullFlavor is not present:
    Slice: Unordered, Open by profile:act, profile:observation
    .... entry:instructionAct 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 InstructionActivity
    ..... 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:instructionObservation 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 1..1 InstructionObservation
    ..... 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 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 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:instructionAct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:instructionObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:instructionAct.typeId, Section.entry:instructionObservation.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-instruction error Section If section/@nullFlavor is not present, SHALL contain at least one Instruction nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists()
    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: shall-instruction
    ... @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 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: 2.16.840.1.113883.10.20.22.2.45
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Instructions
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 69730-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry If section/@nullFlavor is not present:
    Slice: Unordered, Open by profile:act, profile:observation
    .... entry:instructionAct 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 InstructionActivity
    ..... 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:instructionObservation 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 1..1 InstructionObservation
    ..... 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 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 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:instructionAct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:instructionObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:instructionAct.typeId, Section.entry:instructionObservation.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-instruction error Section If section/@nullFlavor is not present, SHALL contain at least one Instruction nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists()

    This structure is derived from Section

    Summary

    Mandatory: 9 elements(2 nested mandatory elements)

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

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

    Differential View

    This structure is derived from Section

    NameFlagsCard.TypeDescription & 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: shall-instruction
    ... @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: 2.16.840.1.113883.10.20.22.2.45
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... code 1..1 CE Instructions
    .... @code 1..1 cs Required Pattern: 69730-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... text 1..1 xhtml
    ... Slices for entry 0..* Entry If section/@nullFlavor is not present:
    Slice: Unordered, Open by profile:act, profile:observation
    .... entry:instructionAct 0..* Entry
    ..... act 1..1 InstructionActivity
    .... entry:instructionObservation 0..* Entry
    ..... observation 1..1 InstructionObservation

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    shall-instruction error Section If section/@nullFlavor is not present, SHALL contain at least one Instruction nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists()

    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: shall-instruction
    ... @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 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: 2.16.840.1.113883.10.20.22.2.45
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Instructions
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 69730-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry If section/@nullFlavor is not present:
    Slice: Unordered, Open by profile:act, profile:observation
    .... entry:instructionAct 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 InstructionActivity
    ..... 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:instructionObservation 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 1..1 InstructionObservation
    ..... 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 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 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:instructionAct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:instructionObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:instructionAct.typeId, Section.entry:instructionObservation.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-instruction error Section If section/@nullFlavor is not present, SHALL contain at least one Instruction nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists()

    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: shall-instruction
    ... @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 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: 2.16.840.1.113883.10.20.22.2.45
    ..... @extension 1..1 st Required Pattern: 2014-06-09
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Instructions
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 69730-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... Slices for entry 0..* Entry If section/@nullFlavor is not present:
    Slice: Unordered, Open by profile:act, profile:observation
    .... entry:instructionAct 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 InstructionActivity
    ..... 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:instructionObservation 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 1..1 InstructionObservation
    ..... 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 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 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:instructionAct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionAct.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:instructionObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:instructionObservation.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:instructionAct.typeId, Section.entry:instructionObservation.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-instruction error Section If section/@nullFlavor is not present, SHALL contain at least one Instruction nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionActivity')).exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/InstructionObservation')).exists()

    This structure is derived from Section

    Summary

    Mandatory: 9 elements(2 nested mandatory elements)

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

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

     

    Other representations of profile: CSV, Excel