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

Logical Model: PhysicalExamSection - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the PhysicalExamSection logical model.

Guidance on how to interpret the contents of this table can be found here

0. Section
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. Section.templateId
Control1..?
SlicingThis element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Section.templateId:section
    Slice Namesection
    Control1..1
    6. Section.templateId:section.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.2.10
    8. Section.templateId:section.extension
    Control1..?
    Pattern Value2015-08-01
    10. Section.code
    ShortPhysical findings Narrative
    Control1..?
    12. Section.code.code
    Control1..?
    Pattern Value29545-1
    14. Section.code.codeSystem
    Control1..?
    Pattern Value2.16.840.1.113883.6.1
    16. Section.title
    Control1..?
    18. Section.text
    Control1..?
    20. Section.entry
    SlicingThis element introduces a set of slices on Section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ observation
    • 22. Section.entry:longCareWound
      Slice NamelongCareWound
      Comments

      MAY contain zero or more [0..*] entry (CONF:1198-31926) such that it

      Control0..*
      24. Section.entry:longCareWound.observation
      Comments

      SHALL contain exactly one [1..1] Longitudinal Care Wound Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.114:2015-08-01) (CONF:1198-31927).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Longitudinal Care Wound Observation)
      26. Section.component
      Comments

      MAY contain zero or more [0..*] component (CONF:1198-32434) such that it

      28. Section.component.section
      Comments

      SHALL contain exactly one [1..1] section (CONF:1198-32435).

      30. Section.component.section.code
      Comments

      This section SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Physical Exam Type urn:oid:2.16.840.1.113883.11.20.9.65 DYNAMIC (CONF:1198-32436).

      Control1..?
      BindingThe codes SHOULD be taken from Physical Exam Type .
      (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65)
      32. Section.component.section.title
      Comments

      This section SHALL contain exactly one [1..1] title (CONF:1198-32437).

      Control1..?
      34. Section.component.section.text
      Comments

      This section SHALL contain exactly one [1..1] text (CONF:1198-32438).

      Control1..?