Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot 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-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: Physical Exam Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection Version: 4.0.0-ballot
Draft as of 2024-12-19 Computable Name: PhysicalExamSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.2.10:2015-08-01

The section includes direct observations made by a clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient's body.

It also includes observations made by the examining clinician using only inspection, palpation, auscultation, and percussion. It does not include laboratory or imaging findings.

The exam may be limited to pertinent body systems based on the patient's chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically.

The Physical Exam Section may contain multiple nested subsections.

Usage:

Formal Views of Template Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Physical findings Narrative
.... @code 1..1 cs Required Pattern: 29545-1
.... @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:longCareWound 0..* Entry
..... observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
... component 0..* InfrastructureRoot
.... section 1..1 Section
..... code 1..1 CE Binding: Physical Exam Type . (preferred)
..... title 1..1 ST
..... text 1..1 xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Section.component.section.codepreferredPhysicalExamType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... 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: 2.16.840.1.113883.10.20.2.10
..... @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 Physical findings Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 29545-1
.... @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:longCareWound 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @ID 0..1 xs:ID
..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..1 II
..... code 1..1 CE Binding: Physical Exam Type . (preferred)
..... 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
..... entry 0..* Entry
..... component 0..* InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Fixed Value: COMP
...... @contextConductionInd 0..1 bl Fixed Value: true
...... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.component.section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.component.section.codepreferredPhysicalExamType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
Section.component.section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... 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: 2.16.840.1.113883.10.20.2.10
..... @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 Physical findings Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 29545-1
.... @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:longCareWound 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @ID 0..1 xs:ID
..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..1 II
..... code 1..1 CE Binding: Physical Exam Type . (preferred)
..... 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
..... entry 0..* Entry
..... component 0..* InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Fixed Value: COMP
...... @contextConductionInd 0..1 bl Fixed Value: true
...... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.component.section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.component.section.codepreferredPhysicalExamType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
Section.component.section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements(4 nested mandatory elements)

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 & Constraintsdoco
.. Section Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Physical findings Narrative
.... @code 1..1 cs Required Pattern: 29545-1
.... @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:longCareWound 0..* Entry
..... observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
... component 0..* InfrastructureRoot
.... section 1..1 Section
..... code 1..1 CE Binding: Physical Exam Type . (preferred)
..... title 1..1 ST
..... text 1..1 xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Section.component.section.codepreferredPhysicalExamType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... 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: 2.16.840.1.113883.10.20.2.10
..... @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 Physical findings Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 29545-1
.... @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:longCareWound 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @ID 0..1 xs:ID
..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..1 II
..... code 1..1 CE Binding: Physical Exam Type . (preferred)
..... 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
..... entry 0..* Entry
..... component 0..* InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Fixed Value: COMP
...... @contextConductionInd 0..1 bl Fixed Value: true
...... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.component.section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.component.section.codepreferredPhysicalExamType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
Section.component.section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... 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: 2.16.840.1.113883.10.20.2.10
..... @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 Physical findings Narrative
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 29545-1
.... @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:longCareWound 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @ID 0..1 xs:ID
..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
..... id 0..1 II
..... code 1..1 CE Binding: Physical Exam Type . (preferred)
..... 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
..... entry 0..* Entry
..... component 0..* InfrastructureRoot
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @typeCode 0..1 cs Fixed Value: COMP
...... @contextConductionInd 0..1 bl Fixed Value: true
...... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.component.section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.component.section.codepreferredPhysicalExamType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
Section.component.section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements(4 nested mandatory elements)

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