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: Postprocedure Diagnosis

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis Version: 4.0.0
Draft as of 2025-10-02 Computable Name: PostprocedureDiagnosis
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.51:2015-08-01

This template represents the diagnosis or diagnoses discovered or confirmed during the procedure. They may be the same as preprocedure diagnoses or indications.

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Required EntryRelationships: ProblemObservation

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 Act

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act 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)
    Constraints: should-text-ref-value
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:postprocedure-dx 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Fixed Value: ACT
    ... @moodCode 1..1 cs Fixed Value: EVN
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... observation 1..1 ProblemObservation

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    should-text-ref-value warning Act SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Act.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
    .. Act C 1..1 Act 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)
    Constraints: should-text-ref-value
    ... @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:postprocedure-dx 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: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @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
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... 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 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 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 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 ProblemObservation
    ..... 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)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Act.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.templateId:postprocedure-dx.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.classCode Base required x_ActClassDocumentEntryAct 📍2.0.0 THO v5.2
    Act.moodCode Base required x_DocumentActMood 📍2.0.0 THO v5.2
    Act.code Base example v3 Code System ActCode 📦3.0.0 THO v6.5
    Act.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Act.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Act.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Act.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Act.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Act.entryRelationship:problemObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Act.typeId, Act.entryRelationship:problemObservation.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning Act SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Act.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
    .. Act C 1..1 Act 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)
    Constraints: should-text-ref-value
    ... @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:postprocedure-dx 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: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @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
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... 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 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 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 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 ProblemObservation
    ..... 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)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Act.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.templateId:postprocedure-dx.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.classCode Base required x_ActClassDocumentEntryAct 📍2.0.0 THO v5.2
    Act.moodCode Base required x_DocumentActMood 📍2.0.0 THO v5.2
    Act.code Base example v3 Code System ActCode 📦3.0.0 THO v6.5
    Act.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Act.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Act.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Act.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Act.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Act.entryRelationship:problemObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Act.typeId, Act.entryRelationship:problemObservation.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning Act SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Act.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 Act

    Summary

    Mandatory: 9 elements
    Fixed: 3 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 Act.templateId
    • The element 1 is sliced based on the value of Act.entryRelationship

    Differential View

    This structure is derived from Act

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act 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)
    Constraints: should-text-ref-value
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:postprocedure-dx 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Fixed Value: ACT
    ... @moodCode 1..1 cs Fixed Value: EVN
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... observation 1..1 ProblemObservation

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    should-text-ref-value warning Act SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Act.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act 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)
    Constraints: should-text-ref-value
    ... @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:postprocedure-dx 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: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @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
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... 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 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 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 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 ProblemObservation
    ..... 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)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Act.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.templateId:postprocedure-dx.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.classCode Base required x_ActClassDocumentEntryAct 📍2.0.0 THO v5.2
    Act.moodCode Base required x_DocumentActMood 📍2.0.0 THO v5.2
    Act.code Base example v3 Code System ActCode 📦3.0.0 THO v6.5
    Act.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Act.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Act.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Act.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Act.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Act.entryRelationship:problemObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Act.typeId, Act.entryRelationship:problemObservation.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning Act SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Act.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
    .. Act C 1..1 Act 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)
    Constraints: should-text-ref-value
    ... @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:postprocedure-dx 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: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @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
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... 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 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 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 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 ProblemObservation
    ..... 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)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Act.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.templateId:postprocedure-dx.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.classCode Base required x_ActClassDocumentEntryAct 📍2.0.0 THO v5.2
    Act.moodCode Base required x_DocumentActMood 📍2.0.0 THO v5.2
    Act.code Base example v3 Code System ActCode 📦3.0.0 THO v6.5
    Act.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Act.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Act.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Act.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Act.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Act.entryRelationship:problemObservation.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Act.entryRelationship:problemObservation.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Act.typeId, Act.entryRelationship:problemObservation.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning Act SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Act.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 Act

    Summary

    Mandatory: 9 elements
    Fixed: 3 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 Act.templateId
    • The element 1 is sliced based on the value of Act.entryRelationship

     

    Other representations of profile: CSV, Excel