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: Notes Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/NotesSection Version: 4.0.0
Draft as of 2025-10-02 Computable Name: NotesSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.65:2016-11-01

The Notes Section allow for inclusion of clinical documentation which does not fit precisely within any other C-CDA section. Multiple Notes sections may be included in a document provided they each include different types of note content as indicated by a different section.code. The Notes Section SHOULD NOT be used in place of a more specific C-CDA section. For example, notes about procedure should be placed within the Procedures Section, not a Notes Section. When a Notes Section is present, Note Activity entries contain structured information about the note information allowing it to be more machine processable.

Templates Used

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

Required Entries: NoteActivity

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-note-activity
    ... 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: 2.16.840.1.113883.10.20.22.2.65
    ..... @extension 1..1 st Required Pattern: 2016-11-01
    ... code 1..1 CE Binding: Note Types . (preferred)
    .... @code 1..1 cs
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST This title should reflect the kind of notes included in this section, corresponding to the code.
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:act
    .... entry:note 0..* Entry If section/@nullFlavor is not present:
    ..... act 1..1 NoteActivity

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Section.code Base preferred Note Types . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    shall-note-activity error Section If section/@nullFlavor is not present, SHALL contain at least one Note Activity nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity')).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-note-activity
    ... @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: 2.16.840.1.113883.10.20.22.2.65
    ..... @extension 1..1 st Required Pattern: 2016-11-01
    ... @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 Binding: Note Types . (preferred)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs
    .... @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 This title should reflect the kind of notes included in this section, corresponding to the code.
    ... text 1..1 xhtml The narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers. While allowed by CDA, the use of renderMultiMedia elements, which contain a referencedObject attribute pointing to an observationMedia or regionOfInterest element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.
    ... 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:act
    .... entry:note 0..* Entry If section/@nullFlavor is not present:
    ..... @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 NoteActivity
    ..... 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 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 Base preferred Note Types . 📦20240606 VSAC v0.23
    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:note.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.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:note.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-note-activity error Section If section/@nullFlavor is not present, SHALL contain at least one Note Activity nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity')).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-note-activity
    ... @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: 2.16.840.1.113883.10.20.22.2.65
    ..... @extension 1..1 st Required Pattern: 2016-11-01
    ... @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 Binding: Note Types . (preferred)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs
    .... @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 This title should reflect the kind of notes included in this section, corresponding to the code.
    ... text 1..1 xhtml The narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers. While allowed by CDA, the use of renderMultiMedia elements, which contain a referencedObject attribute pointing to an observationMedia or regionOfInterest element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.
    ... 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:act
    .... entry:note 0..* Entry If section/@nullFlavor is not present:
    ..... @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 NoteActivity
    ..... 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 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 Base preferred Note Types . 📦20240606 VSAC v0.23
    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:note.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.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:note.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-note-activity error Section If section/@nullFlavor is not present, SHALL contain at least one Note Activity nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity')).exists()

    This structure is derived from Section

    Summary

    Mandatory: 9 elements(1 nested mandatory element)

    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 1 is sliced based on the value 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-note-activity
    ... 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: 2.16.840.1.113883.10.20.22.2.65
    ..... @extension 1..1 st Required Pattern: 2016-11-01
    ... code 1..1 CE Binding: Note Types . (preferred)
    .... @code 1..1 cs
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST This title should reflect the kind of notes included in this section, corresponding to the code.
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:act
    .... entry:note 0..* Entry If section/@nullFlavor is not present:
    ..... act 1..1 NoteActivity

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Section.code Base preferred Note Types . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    shall-note-activity error Section If section/@nullFlavor is not present, SHALL contain at least one Note Activity nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity')).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-note-activity
    ... @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: 2.16.840.1.113883.10.20.22.2.65
    ..... @extension 1..1 st Required Pattern: 2016-11-01
    ... @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 Binding: Note Types . (preferred)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs
    .... @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 This title should reflect the kind of notes included in this section, corresponding to the code.
    ... text 1..1 xhtml The narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers. While allowed by CDA, the use of renderMultiMedia elements, which contain a referencedObject attribute pointing to an observationMedia or regionOfInterest element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.
    ... 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:act
    .... entry:note 0..* Entry If section/@nullFlavor is not present:
    ..... @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 NoteActivity
    ..... 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 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 Base preferred Note Types . 📦20240606 VSAC v0.23
    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:note.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.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:note.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-note-activity error Section If section/@nullFlavor is not present, SHALL contain at least one Note Activity nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity')).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-note-activity
    ... @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: 2.16.840.1.113883.10.20.22.2.65
    ..... @extension 1..1 st Required Pattern: 2016-11-01
    ... @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 Binding: Note Types . (preferred)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs
    .... @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 This title should reflect the kind of notes included in this section, corresponding to the code.
    ... text 1..1 xhtml The narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers. While allowed by CDA, the use of renderMultiMedia elements, which contain a referencedObject attribute pointing to an observationMedia or regionOfInterest element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.
    ... 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:act
    .... entry:note 0..* Entry If section/@nullFlavor is not present:
    ..... @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 NoteActivity
    ..... 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 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 Base preferred Note Types . 📦20240606 VSAC v0.23
    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:note.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:note.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:note.typeId, Section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    shall-note-activity error Section If section/@nullFlavor is not present, SHALL contain at least one Note Activity nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity')).exists()

    This structure is derived from Section

    Summary

    Mandatory: 9 elements(1 nested mandatory element)

    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 1 is sliced based on the value of Section.entry

     

    Other representations of profile: CSV, Excel