Consolidated CDA (C-CDA)
4.0.0 - STU4
Consolidated CDA (C-CDA)
4.0.0 - STU4
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0 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/OperativeNoteSurgicalProcedureSection | Version: 4.0.0 | |||
| Draft as of 2025-10-02 | Computable Name: OperativeNoteSurgicalProcedureSection | |||
| Other Identifiers: OID:2.16.840.1.113883.10.20.7.14 | ||||
The Operative Note Surgical Procedure Section can be used to restate the procedures performed if appropriate for an enterprise workflow. The procedure(s) performed associated with the Operative Note are formally modeled in the header using serviceEvent.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 3.0.0:
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 |
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: 2.16.840.1.113883.10.20.7.14 | |
  @extension |
0..0 | |||
| code |
1..1 | CE | Surgical operation note surgical procedure Narrative | |
 @code |
1..1 | cs | Required Pattern: 10223-6 | |
 @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | There SHALL be text indicating the procedure performed (CONF:81-8054). | |
| 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: 2.16.840.1.113883.10.20.7.14 | |
| @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 | Surgical operation note surgical procedure Narrative | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 10223-6 | |
| @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 | There SHALL be text indicating the procedure performed (CONF:81-8054). | |
| 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 | 📦2.0.1-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.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 |
| 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: 2.16.840.1.113883.10.20.7.14 | |
| @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 | Surgical operation note surgical procedure Narrative | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 10223-6 | |
| @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 | There SHALL be text indicating the procedure performed (CONF:81-8054). | |
| 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 | 📦2.0.1-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.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 |
| 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 |
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: 2.16.840.1.113883.10.20.7.14 | |
| @extension |
0..0 | |||
| code |
1..1 | CE | Surgical operation note surgical procedure Narrative | |
| @code |
1..1 | cs | Required Pattern: 10223-6 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | There SHALL be text indicating the procedure performed (CONF:81-8054). | |
| 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: 2.16.840.1.113883.10.20.7.14 | |
| @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 | Surgical operation note surgical procedure Narrative | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 10223-6 | |
| @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 | There SHALL be text indicating the procedure performed (CONF:81-8054). | |
| 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 | 📦2.0.1-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.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 |
| 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: 2.16.840.1.113883.10.20.7.14 | |
| @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 | Surgical operation note surgical procedure Narrative | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 10223-6 | |
| @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 | There SHALL be text indicating the procedure performed (CONF:81-8054). | |
| 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 | 📦2.0.1-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.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 |
| 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#4.0.0 based on FHIR 5.0.0. Generated 2025-10-02
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