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-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/PastMedicalHistory | Version: 4.0.0-ballot | |||
Draft as of 2024-12-19 | Computable Name: PastMedicalHistory | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.20:2015-08-01 |
This section contains a record of the patient's past complaints, problems, and diagnoses. It contains data from the patient's past up to the patient's current complaint or reason for seeking medical care.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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: 2.16.840.1.113883.10.20.22.2.20 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | History of Past illness Narrative | |
@code | 1..1 | cs | Required Pattern: 11348-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | |
entry:problem | 0..* | Entry | ||
observation | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). | |
effectiveTime | C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
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: 2.16.840.1.113883.10.20.22.2.20 | |||||||
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |||||||
@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 | History of Past illness Narrative | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Required Pattern: 11348-0 | |||||||
@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 | Slice: Unordered, Open by profile:observation | |||||||
entry:problem | 0..* | Entry | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
templateId:problem-obs | 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: 2.16.840.1.113883.10.20.22.4.4 | |||||||
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
@negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | Binding: Problem Type (preferred) | |||||||
derivationExpr | 0..1 | ST | ||||||||
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@compression | 0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
@integrityCheck | 0..1 | bin | ||||||||
@integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
@language | 0..1 | cs | ||||||||
@mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
@representation | 0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
thumbnail | 0..1 | ED | ||||||||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Fixed Value: completed | |||||||
@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) | |||||||
effectiveTime | C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |||||||
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
center | 0..1 | TS | ||||||||
width | 0..1 | PQ | ||||||||
high | 0..1 | IVXB_TS | 𝗨𝗦𝗖𝗗𝗜: Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
value | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding Description (No ValueSet): (example): See additional binding
| |||||||
@codeSystem | 0..1 | oid, uuid, ruid | ||||||||
@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 | ||||||||
qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
translation | 0..* | CD | ||||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |||||||
entryRelationship:age | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
@inversionInd | 1..1 | bl | Fixed Value: true | |||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priority | 0..* | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:status | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Date of Diagnosis | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
reference | 0..* | Reference | ||||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
observationRange | 1..1 | ObservationRange | ||||||||
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
Section.entry:problem.observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.templateId:problem-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Section.entry:problem.observation.code | preferred | ProblemType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
Section.entry:problem.observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Section.entry:problem.observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Section.entry:problem.observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Section.entry:problem.observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Section.entry:problem.observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
Section.entry:problem.observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Section.entry:problem.observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
Section.entry:problem.observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.value.code | example | ||
Section.entry:problem.observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Section.entry:problem.observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Section.entry:problem.observation.entryRelationship:age.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:priority.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.entry:problem.typeId, Section.entry:problem.observation.typeId, Section.entry:problem.observation.entryRelationship:age.typeId, Section.entry:problem.observation.entryRelationship:prognosis.typeId, Section.entry:problem.observation.entryRelationship:priority.typeId, Section.entry:problem.observation.entryRelationship:status.typeId, Section.entry:problem.observation.entryRelationship:reference.typeId, Section.entry:problem.observation.entryRelationship:assessment.typeId, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId, Section.entry:problem.observation.referenceRange.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Section.entry:problem.observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
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: 2.16.840.1.113883.10.20.22.2.20 | |||||||
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |||||||
@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 | History of Past illness Narrative | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Required Pattern: 11348-0 | |||||||
@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 | Slice: Unordered, Open by profile:observation | |||||||
entry:problem | 0..* | Entry | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
templateId:problem-obs | 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: 2.16.840.1.113883.10.20.22.4.4 | |||||||
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
@negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | Binding: Problem Type (preferred) | |||||||
derivationExpr | 0..1 | ST | ||||||||
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@compression | 0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
@integrityCheck | 0..1 | bin | ||||||||
@integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
@language | 0..1 | cs | ||||||||
@mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
@representation | 0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
thumbnail | 0..1 | ED | ||||||||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Fixed Value: completed | |||||||
@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) | |||||||
effectiveTime | C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |||||||
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
center | 0..1 | TS | ||||||||
width | 0..1 | PQ | ||||||||
high | 0..1 | IVXB_TS | 𝗨𝗦𝗖𝗗𝗜: Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
value | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding Description (No ValueSet): (example): See additional binding
| |||||||
@codeSystem | 0..1 | oid, uuid, ruid | ||||||||
@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 | ||||||||
qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
translation | 0..* | CD | ||||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |||||||
entryRelationship:age | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
@inversionInd | 1..1 | bl | Fixed Value: true | |||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priority | 0..* | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:status | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Date of Diagnosis | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
reference | 0..* | Reference | ||||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
observationRange | 1..1 | ObservationRange | ||||||||
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
Section.entry:problem.observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.templateId:problem-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Section.entry:problem.observation.code | preferred | ProblemType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
Section.entry:problem.observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Section.entry:problem.observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Section.entry:problem.observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Section.entry:problem.observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Section.entry:problem.observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
Section.entry:problem.observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Section.entry:problem.observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
Section.entry:problem.observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.value.code | example | ||
Section.entry:problem.observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Section.entry:problem.observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Section.entry:problem.observation.entryRelationship:age.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:priority.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.entry:problem.typeId, Section.entry:problem.observation.typeId, Section.entry:problem.observation.entryRelationship:age.typeId, Section.entry:problem.observation.entryRelationship:prognosis.typeId, Section.entry:problem.observation.entryRelationship:priority.typeId, Section.entry:problem.observation.entryRelationship:status.typeId, Section.entry:problem.observation.entryRelationship:reference.typeId, Section.entry:problem.observation.entryRelationship:assessment.typeId, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId, Section.entry:problem.observation.referenceRange.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Section.entry:problem.observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
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:
Differential View
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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: 2.16.840.1.113883.10.20.22.2.20 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | History of Past illness Narrative | |
@code | 1..1 | cs | Required Pattern: 11348-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | |
entry:problem | 0..* | Entry | ||
observation | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). | |
effectiveTime | C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
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: 2.16.840.1.113883.10.20.22.2.20 | |||||||
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |||||||
@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 | History of Past illness Narrative | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Required Pattern: 11348-0 | |||||||
@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 | Slice: Unordered, Open by profile:observation | |||||||
entry:problem | 0..* | Entry | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
templateId:problem-obs | 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: 2.16.840.1.113883.10.20.22.4.4 | |||||||
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
@negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | Binding: Problem Type (preferred) | |||||||
derivationExpr | 0..1 | ST | ||||||||
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@compression | 0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
@integrityCheck | 0..1 | bin | ||||||||
@integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
@language | 0..1 | cs | ||||||||
@mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
@representation | 0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
thumbnail | 0..1 | ED | ||||||||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Fixed Value: completed | |||||||
@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) | |||||||
effectiveTime | C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |||||||
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
center | 0..1 | TS | ||||||||
width | 0..1 | PQ | ||||||||
high | 0..1 | IVXB_TS | 𝗨𝗦𝗖𝗗𝗜: Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
value | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding Description (No ValueSet): (example): See additional binding
| |||||||
@codeSystem | 0..1 | oid, uuid, ruid | ||||||||
@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 | ||||||||
qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
translation | 0..* | CD | ||||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |||||||
entryRelationship:age | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
@inversionInd | 1..1 | bl | Fixed Value: true | |||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priority | 0..* | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:status | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Date of Diagnosis | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
reference | 0..* | Reference | ||||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
observationRange | 1..1 | ObservationRange | ||||||||
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
Section.entry:problem.observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.templateId:problem-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Section.entry:problem.observation.code | preferred | ProblemType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
Section.entry:problem.observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Section.entry:problem.observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Section.entry:problem.observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Section.entry:problem.observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Section.entry:problem.observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
Section.entry:problem.observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Section.entry:problem.observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
Section.entry:problem.observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.value.code | example | ||
Section.entry:problem.observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Section.entry:problem.observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Section.entry:problem.observation.entryRelationship:age.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:priority.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.entry:problem.typeId, Section.entry:problem.observation.typeId, Section.entry:problem.observation.entryRelationship:age.typeId, Section.entry:problem.observation.entryRelationship:prognosis.typeId, Section.entry:problem.observation.entryRelationship:priority.typeId, Section.entry:problem.observation.entryRelationship:status.typeId, Section.entry:problem.observation.entryRelationship:reference.typeId, Section.entry:problem.observation.entryRelationship:assessment.typeId, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId, Section.entry:problem.observation.referenceRange.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Section.entry:problem.observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
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: 2.16.840.1.113883.10.20.22.2.20 | |||||||
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |||||||
@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 | History of Past illness Narrative | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Required Pattern: 11348-0 | |||||||
@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 | Slice: Unordered, Open by profile:observation | |||||||
entry:problem | 0..* | Entry | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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, value:extension | |||||||
templateId:problem-obs | 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: 2.16.840.1.113883.10.20.22.4.4 | |||||||
@extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
@negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | Binding: Problem Type (preferred) | |||||||
derivationExpr | 0..1 | ST | ||||||||
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@compression | 0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
@integrityCheck | 0..1 | bin | ||||||||
@integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
@language | 0..1 | cs | ||||||||
@mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
@representation | 0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
thumbnail | 0..1 | ED | ||||||||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 1..1 | cs | Fixed Value: completed | |||||||
@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) | |||||||
effectiveTime | C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high | ||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |||||||
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
center | 0..1 | TS | ||||||||
width | 0..1 | PQ | ||||||||
high | 0..1 | IVXB_TS | 𝗨𝗦𝗖𝗗𝗜: Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
value | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
@code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding Description (No ValueSet): (example): See additional binding
| |||||||
@codeSystem | 0..1 | oid, uuid, ruid | ||||||||
@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 | ||||||||
qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
translation | 0..* | CD | ||||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |||||||
entryRelationship:age | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
@inversionInd | 1..1 | bl | Fixed Value: true | |||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priority | 0..* | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:status | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | 0..1 | Act | ||||||||
encounter | 0..1 | Encounter | ||||||||
observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Date of Diagnosis | |||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
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 | ||||||||
reference | 0..* | Reference | ||||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
realmCode | 0..* | CS | ||||||||
typeId | C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
observationRange | 1..1 | ObservationRange | ||||||||
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
@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 | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
Section.entry:problem.observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.templateId:problem-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Section.entry:problem.observation.code | preferred | ProblemType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
Section.entry:problem.observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Section.entry:problem.observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Section.entry:problem.observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Section.entry:problem.observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Section.entry:problem.observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
Section.entry:problem.observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Section.entry:problem.observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
Section.entry:problem.observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.value.code | example | ||
Section.entry:problem.observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Section.entry:problem.observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Section.entry:problem.observation.entryRelationship:age.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:priority.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Section.entry:problem.observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:problem.observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.entry:problem.typeId, Section.entry:problem.observation.typeId, Section.entry:problem.observation.entryRelationship:age.typeId, Section.entry:problem.observation.entryRelationship:prognosis.typeId, Section.entry:problem.observation.entryRelationship:priority.typeId, Section.entry:problem.observation.entryRelationship:status.typeId, Section.entry:problem.observation.entryRelationship:reference.typeId, Section.entry:problem.observation.entryRelationship:assessment.typeId, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId, Section.entry:problem.observation.referenceRange.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Section.entry:problem.observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
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: