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: Postprocedure Diagnosis

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis Version: 4.0.0-ballot
Draft as of 2024-12-19 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.

Usage:

Formal Views of Template Content

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

This structure is derived from Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@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 value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... 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 Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @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: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 value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... 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 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 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 C 1..1 ProblemObservation 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
... 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

PathConformanceValueSet / CodeURI
Act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningAct.entryRelationship:problemObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @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: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 value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... 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 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 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 C 1..1 ProblemObservation 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
... 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

PathConformanceValueSet / CodeURI
Act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningAct.entryRelationship:problemObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf 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 & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@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 value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... 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 Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf 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 & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @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: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 value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... 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 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 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 C 1..1 ProblemObservation 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
... 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

PathConformanceValueSet / CodeURI
Act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningAct.entryRelationship:problemObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf 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 & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @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: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 value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... 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 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 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 C 1..1 ProblemObservation 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
... 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

PathConformanceValueSet / CodeURI
Act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-authorwarningAct.entryRelationship:problemObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf 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