Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 - Ballot 1
Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 - Ballot 1
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicalGeneralHistorySection | Version: 5.0.0-ballot | |||
| Draft as of 2025-12-04 | Computable Name: MedicalGeneralHistorySection | |||
| Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.39 | ||||
The Medical History Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 4.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  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) | |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
   templateId:section |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
  @extension |
0..0 | |||
| code |
1..1 | CE | Medical (General) History | |
 @code |
1..1 | cs | Required Pattern: 11329-0 | |
 @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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: 2.16.840.1.113883.10.20.22.2.39 | |
| @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 | Medical (General) History | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 11329-0 | |
| @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 | ||
| entry |
0..* | Entry | ||
 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 | ||
| Documentation for this format | ||||
| 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 |
| 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()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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: 2.16.840.1.113883.10.20.22.2.39 | |
| @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 | Medical (General) History | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 11329-0 | |
| @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 | ||
| entry |
0..* | Entry | ||
| 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 | ||
| Documentation for this format | ||||
| 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 |
| 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()
|
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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) | |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| templateId:section |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
| @extension |
0..0 | |||
| code |
1..1 | CE | Medical (General) History | |
| @code |
1..1 | cs | Required Pattern: 11329-0 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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: 2.16.840.1.113883.10.20.22.2.39 | |
| @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 | Medical (General) History | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 11329-0 | |
| @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 | ||
| entry |
0..* | Entry | ||
| 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 | ||
| Documentation for this format | ||||
| 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 |
| 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
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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: 2.16.840.1.113883.10.20.22.2.39 | |
| @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 | Medical (General) History | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 11329-0 | |
| @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 | ||
| entry |
0..* | Entry | ||
| 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 | ||
| Documentation for this format | ||||
| 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 |
| 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()
|
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#5.0.0-ballot based on FHIR 5.0.0. Generated 2025-12-04
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