Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 Ballot 1 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 5.0.0-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: 5.0.0-ballot
Draft as of 2025-12-12 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.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 4.0.0:

  • 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: 2.16.840.1.113883.10.20.2.10
    ..... @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 Label of a section
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
    .... entry:longCareWound 0..* Entry
    ..... observation 1..1 LongitudinalCareWoundObservation
    ... component 0..* InfrastructureRoot Used to nest a Section within a Section
    .... section 1..1 Section
    ..... code 1..1 CE Kind of section
    Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST Label of a section
    ..... text 1..1 xhtml Narrative to be rendered

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Section.component.section.​code Base preferred Physical Exam Type . 📦20250806 VSAC v0.24
    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: 2.16.840.1.113883.10.20.2.10
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... 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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... 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 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 LongitudinalCareWoundObservation
    ..... 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 Used to nest a Section within a Section
    .... @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
    ..... @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
    ..... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ..... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ..... id 0..1 II Unique instance identifier of a particular document section
    ..... code 1..1 CE Kind of section
    Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST Label of a section
    ..... text 1..1 xhtml Narrative to be rendered
    ..... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ..... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ..... subject 0..1 Subject Primary target of the entries recorded in a section
    ..... author 0..* Author
    ..... informant 0..* Informant
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot Used to nest a Section within a Section
    ...... @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 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:longCareWound.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.component.section.​moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​code Base preferred Physical Exam Type . 📦20250806 VSAC v0.24
    Section.component.section.​languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.section.​component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​component.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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: 2.16.840.1.113883.10.20.2.10
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... 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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... 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 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 LongitudinalCareWoundObservation
    ..... 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 Used to nest a Section within a Section
    .... @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
    ..... @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
    ..... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ..... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ..... id 0..1 II Unique instance identifier of a particular document section
    ..... code 1..1 CE Kind of section
    Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST Label of a section
    ..... text 1..1 xhtml Narrative to be rendered
    ..... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ..... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ..... subject 0..1 Subject Primary target of the entries recorded in a section
    ..... author 0..* Author
    ..... informant 0..* Informant
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot Used to nest a Section within a Section
    ...... @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 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:longCareWound.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.component.section.​moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​code Base preferred Physical Exam Type . 📦20250806 VSAC v0.24
    Section.component.section.​languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.section.​component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​component.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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 & 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: 2.16.840.1.113883.10.20.2.10
    ..... @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 Label of a section
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
    .... entry:longCareWound 0..* Entry
    ..... observation 1..1 LongitudinalCareWoundObservation
    ... component 0..* InfrastructureRoot Used to nest a Section within a Section
    .... section 1..1 Section
    ..... code 1..1 CE Kind of section
    Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST Label of a section
    ..... text 1..1 xhtml Narrative to be rendered

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Section.component.section.​code Base preferred Physical Exam Type . 📦20250806 VSAC v0.24

    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: 2.16.840.1.113883.10.20.2.10
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... 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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... 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 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 LongitudinalCareWoundObservation
    ..... 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 Used to nest a Section within a Section
    .... @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
    ..... @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
    ..... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ..... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ..... id 0..1 II Unique instance identifier of a particular document section
    ..... code 1..1 CE Kind of section
    Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST Label of a section
    ..... text 1..1 xhtml Narrative to be rendered
    ..... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ..... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ..... subject 0..1 Subject Primary target of the entries recorded in a section
    ..... author 0..* Author
    ..... informant 0..* Informant
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot Used to nest a Section within a Section
    ...... @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 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:longCareWound.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.component.section.​moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​code Base preferred Physical Exam Type . 📦20250806 VSAC v0.24
    Section.component.section.​languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.section.​component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​component.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

    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: 2.16.840.1.113883.10.20.2.10
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II Unique instance identifier of a particular document section
    ... 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 Label of a section
    ... text 1..1 xhtml Narrative to be rendered
    ... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ... subject 0..1 Subject Primary target of the entries recorded in a section
    ... 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 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 LongitudinalCareWoundObservation
    ..... 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 Used to nest a Section within a Section
    .... @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
    ..... @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
    ..... @ID 0..1 xs:ID Can serve as a target of a linkHtml reference
    ..... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ..... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ..... id 0..1 II Unique instance identifier of a particular document section
    ..... code 1..1 CE Kind of section
    Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST Label of a section
    ..... text 1..1 xhtml Narrative to be rendered
    ..... confidentialityCode 0..1 CE Controls the disclosure of information in this section
    ..... languageCode 0..1 CS Human language of character data
    Binding: AllLanguages (required)
    ..... subject 0..1 Subject Primary target of the entries recorded in a section
    ..... author 0..* Author
    ..... informant 0..* Informant
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot Used to nest a Section within a Section
    ...... @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 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.templateId:section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.code.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.entry:longCareWound.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.entry:longCareWound.​typeCode Base required x_ActRelationshipEntry 📦3.0.0 THO v7.0
    Section.component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​classCode Base required ActClassRecordOrganizer 📦3.0.0 THO v7.0
    Section.component.section.​moodCode Base required CDAActMood 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​code Base preferred Physical Exam Type . 📦20250806 VSAC v0.24
    Section.component.section.​languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Section.component.section.​component.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0
    Section.component.section.​component.typeId.nullFlavor Base required CDANullFlavor 📦2.0.2-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Section.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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