Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: Past Medical History

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PastMedicalHistory Version: 4.0.0
Draft as of 2025-10-02 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.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 3.0.0:

  • New Content

    • Formal Views of Template Content

    Description of Template, Differentials, Snapshots and how the different presentations work.

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section Section XML Namespace: urn:hl7-org:v3
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, 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
    ... 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.
    Constraints: should-high
    ....... high 0..1 IVXB_TS SHOULD contain high

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    should-high warning Section.entry:problem.observation.effectiveTime SHOULD contain high high.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... 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 Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
    ..... @contextConductionInd 0..1 bl Fixed Value: true
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation SHOULD contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ....... @assigningAuthorityName 0..1 st
    ....... @displayable 0..1 bl
    ....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ....... @extension 1..1 st
    ...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, 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 Constraints: value-starts-octothorpe
    ....... 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.
    Constraints: should-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 SHOULD contain high
    ...... 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: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations
    ....... @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
    ...... 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AgeObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PrognosisObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PriorityPreference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 ProblemStatus
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 EntryReference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AssessmentScaleObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 DateOfDiagnosisAct
    ........ 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 Constraints: II-1
    ........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ........ @assigningAuthorityName 0..1 st
    ........ @displayable 0..1 bl
    ........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ........ @extension 1..1 st
    ....... templateId 0..* II
    ....... @typeCode 0..1 cs Binding: 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.templateId:problem-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.code Base preferred Problem Type . 📦20250428 VSAC v0.23
    Section.entry:problem.​observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​observation.value Base preferred US Core Condition Codes 📦8.0.0 US Core v8.0
    Section.entry:problem.​observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.value.code Base example ? Unknown
    Section.entry:problem.​observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:age.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:prognosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:priority.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:status.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:reference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:assessment.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry: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-high warning Section.entry:problem.observation.effectiveTime SHOULD contain high high.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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... 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 Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
    ..... @contextConductionInd 0..1 bl Fixed Value: true
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation SHOULD contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ....... @assigningAuthorityName 0..1 st
    ....... @displayable 0..1 bl
    ....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ....... @extension 1..1 st
    ...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, 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 Constraints: value-starts-octothorpe
    ....... 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.
    Constraints: should-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 SHOULD contain high
    ...... 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: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations
    ....... @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
    ...... 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AgeObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PrognosisObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PriorityPreference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 ProblemStatus
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 EntryReference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AssessmentScaleObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 DateOfDiagnosisAct
    ........ 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 Constraints: II-1
    ........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ........ @assigningAuthorityName 0..1 st
    ........ @displayable 0..1 bl
    ........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ........ @extension 1..1 st
    ....... templateId 0..* II
    ....... @typeCode 0..1 cs Binding: 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.templateId:problem-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.code Base preferred Problem Type . 📦20250428 VSAC v0.23
    Section.entry:problem.​observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​observation.value Base preferred US Core Condition Codes 📦8.0.0 US Core v8.0
    Section.entry:problem.​observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.value.code Base example ? Unknown
    Section.entry:problem.​observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:age.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:prognosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:priority.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:status.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:reference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:assessment.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry: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-high warning Section.entry:problem.observation.effectiveTime SHOULD contain high high.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:

    • The element 2 is sliced based on the values of Section.templateId
    • The element 1 is sliced based on the value of Section.entry

    Differential View

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section Section XML Namespace: urn:hl7-org:v3
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, 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
    ... 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.
    Constraints: should-high
    ....... high 0..1 IVXB_TS SHOULD contain high

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    should-high warning Section.entry:problem.observation.effectiveTime SHOULD contain high high.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... 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 Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
    ..... @contextConductionInd 0..1 bl Fixed Value: true
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation SHOULD contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ....... @assigningAuthorityName 0..1 st
    ....... @displayable 0..1 bl
    ....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ....... @extension 1..1 st
    ...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, 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 Constraints: value-starts-octothorpe
    ....... 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.
    Constraints: should-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 SHOULD contain high
    ...... 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: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations
    ....... @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
    ...... 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AgeObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PrognosisObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PriorityPreference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 ProblemStatus
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 EntryReference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AssessmentScaleObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 DateOfDiagnosisAct
    ........ 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 Constraints: II-1
    ........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ........ @assigningAuthorityName 0..1 st
    ........ @displayable 0..1 bl
    ........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ........ @extension 1..1 st
    ....... templateId 0..* II
    ....... @typeCode 0..1 cs Binding: 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.templateId:problem-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.code Base preferred Problem Type . 📦20250428 VSAC v0.23
    Section.entry:problem.​observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​observation.value Base preferred US Core Condition Codes 📦8.0.0 US Core v8.0
    Section.entry:problem.​observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.value.code Base example ? Unknown
    Section.entry:problem.​observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:age.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:prognosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:priority.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:status.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:reference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:assessment.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry: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-high warning Section.entry:problem.observation.effectiveTime SHOULD contain high high.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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... 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 Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
    ..... @contextConductionInd 0..1 bl Fixed Value: true
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation SHOULD contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase).
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ....... @assigningAuthorityName 0..1 st
    ....... @displayable 0..1 bl
    ....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ....... @extension 1..1 st
    ...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, 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 Constraints: value-starts-octothorpe
    ....... 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.
    Constraints: should-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 SHOULD contain high
    ...... 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: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations
    ....... @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
    ...... 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AgeObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PrognosisObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 PriorityPreference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 ProblemStatus
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 EntryReference
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 AssessmentScaleObservation
    ........ 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 Constraints: II-1
    ......... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ......... @assigningAuthorityName 0..1 st
    ......... @displayable 0..1 bl
    ......... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ......... @extension 1..1 st
    ........ templateId 0..* II
    ........ @typeCode 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 1..1 DateOfDiagnosisAct
    ........ 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 Constraints: II-1
    ........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ........ @assigningAuthorityName 0..1 st
    ........ @displayable 0..1 bl
    ........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ........ @extension 1..1 st
    ....... templateId 0..* II
    ....... @typeCode 0..1 cs Binding: 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Section.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v6.5
    Section.moodCode Base required CDAActMood 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.templateId:problem-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.code Base preferred Problem Type . 📦20250428 VSAC v0.23
    Section.entry:problem.​observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Section.entry:problem.​observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.effectiveTime.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:problem.​observation.value Base preferred US Core Condition Codes 📦8.0.0 US Core v8.0
    Section.entry:problem.​observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.value.code Base example ? Unknown
    Section.entry:problem.​observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:age.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:age.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:prognosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:prognosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:priority.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:priority.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:status.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:status.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:reference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:reference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:assessment.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:assessment.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.entryRelationship:dateOfDiagnosis.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Section.entry:problem.​observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.entry:problem.​observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry: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-high warning Section.entry:problem.observation.effectiveTime SHOULD contain high high.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:

    • The element 2 is sliced based on the values of Section.templateId
    • The element 1 is sliced based on the value of Section.entry

     

    Other representations of profile: CSV, Excel