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

Logical Model: ProcedureNote - Detailed Descriptions

Active as of 2024-12-19

Definitions for the ProcedureNote logical model.

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

0. ClinicalDocument
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantscategory-28570-0: If category is present, then there shall be a category with LOINC code '28570-0'. (sdtcCategory.empty() or sdtcCategory.exists(code = '28570-0' and codeSystem = '2.16.840.1.113883.6.1'))
should-componentOf: SHOULD contain componentOf (componentOf.exists())
2. ClinicalDocument.templateId
Control2..?
4. ClinicalDocument.templateId:procedure-note
Slice Nameprocedure-note
Control1..1
6. ClinicalDocument.templateId:procedure-note.root
Control1..?
Pattern Value2.16.840.1.113883.10.20.22.1.6
8. ClinicalDocument.templateId:procedure-note.extension
Control1..?
Pattern Value2024-05-01
10. ClinicalDocument.sdtcCategory
ShortUsed to categorize the document as a Procedure Note. If present, there SHALL be a category of 28570-0 (Procedure note).
12. ClinicalDocument.code
ShortThe Procedure Note recommends use of a single document type code, 28570-0 "Procedure note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Comments

SHALL contain exactly one [1..1] code (CONF:1198-17182).

BindingThe codes SHALL be taken from ProcedureNoteDocumentTypeCodes .
(required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.6.1)
14. ClinicalDocument.participant
ShortThe participant element in the Procedure Note header follows the General Header Constraints for participants.
SlicingThis element introduces a set of slices on ClinicalDocument.participant. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ typeCode
  • value @ functionCode.code
  • 16. ClinicalDocument.participant:participant1
    Slice Nameparticipant1
    Comments

    MAY contain zero or more [0..*] participant (CONF:1198-8504) such that it

    Control0..*
    18. ClinicalDocument.participant:participant1.typeCode
    Comments

    SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8505).

    Fixed ValueIND
    20. ClinicalDocument.participant:participant1.functionCode
    Comments

    SHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: HL7ParticipationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8506).

    Control1..?
    22. ClinicalDocument.participant:participant1.functionCode.code
    Control1..?
    Pattern ValuePCP
    24. ClinicalDocument.participant:participant1.functionCode.codeSystem
    Control1..?
    Pattern Value2.16.840.1.113883.5.88
    26. ClinicalDocument.participant:participant1.associatedEntity
    28. ClinicalDocument.participant:participant1.associatedEntity.classCode
    Comments

    SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8507).

    Fixed ValuePROV
    30. ClinicalDocument.participant:participant1.associatedEntity.associatedPerson
    Comments

    This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:1198-8508).

    Control1..?
    32. ClinicalDocument.documentationOf
    ShortA serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
    Control1..?
    34. ClinicalDocument.documentationOf.serviceEvent
    Comments

    SHALL contain exactly one [1..1] serviceEvent (CONF:1198-10061).

    36. ClinicalDocument.documentationOf.serviceEvent.code
    Binding

    The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

    Invariants1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). (codeSystem = '2.16.840.1.113883.6.104' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.285' or (codeSystem = '2.16.840.1.113883.6.96' and code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28')))
    38. ClinicalDocument.documentationOf.serviceEvent.effectiveTime
    Comments

    This serviceEvent SHALL contain exactly one [1..1] US Realm Date and Time (Interval) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:1198-10062).

    Invariantswidth-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high. ((width | high).count() = 1)
    40. ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low
    ShortLow is required
    Comments

    This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-26449) / (CONF:1198-8513).

    42. ClinicalDocument.documentationOf.serviceEvent.effectiveTime.width
    ShortRepresents the duration
    Comments

    When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL NOT be present (CONF:1198-8515).

    44. ClinicalDocument.documentationOf.serviceEvent.effectiveTime.high
    ShortEquals low if only the date is known
    Comments

    If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high (CONF:1198-8514).

    46. ClinicalDocument.documentationOf.serviceEvent.performer
    Control1..?
    SlicingThis element introduces a set of slices on ClinicalDocument.documentationOf.serviceEvent.performer. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ typeCode
    • 48. ClinicalDocument.documentationOf.serviceEvent.performer:primary
      Slice Nameprimary
      ShortThis performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
      Comments

      This serviceEvent SHALL contain exactly one [1..1] performer (CONF:1198-8520) such that it

      Control1..1
      50. ClinicalDocument.documentationOf.serviceEvent.performer:primary.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="PPRF" Primary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8521).

      Fixed ValuePPRF
      52. ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity
      Comments

      SHALL contain exactly one [1..1] assignedEntity (CONF:1198-14911).

      Invariantsshould-code: SHOULD contain code (code.exists())
      54. ClinicalDocument.documentationOf.serviceEvent.performer:primary.assignedEntity.code
      Comments

      This assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-14912).

      BindingThe codes SHALL be taken from Healthcare Provider Taxonomy .
      (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066)
      56. ClinicalDocument.documentationOf.serviceEvent.performer:secondary
      Slice Namesecondary
      Comments

      This serviceEvent MAY contain zero or more [0..*] performer (CONF:1198-32732) such that it

      Control0..*
      58. ClinicalDocument.documentationOf.serviceEvent.performer:secondary.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="SPRF" Secondary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-32734).

      Fixed ValueSPRF
      60. ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity
      Comments

      SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32733).

      Invariantsshould-code: SHOULD contain code (code.exists())
      62. ClinicalDocument.documentationOf.serviceEvent.performer:secondary.assignedEntity.code
      Comments

      This assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32735).

      BindingThe codes SHALL be taken from Healthcare Provider Taxonomy .
      (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066)
      64. ClinicalDocument.authorization
      ShortAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
      Comments

      MAY contain zero or one [0..1] authorization (CONF:1198-32412).

      Control0..1
      66. ClinicalDocument.authorization.consent
      Comments

      The authorization, if present, SHALL contain exactly one [1..1] consent (CONF:1198-32414).

      68. ClinicalDocument.authorization.consent.classCode
      Comments

      This consent SHALL contain exactly one [1..1] @classCode="CONS" consent (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-32415).

      Control1..?
      70. ClinicalDocument.authorization.consent.moodCode
      Comments

      This consent SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-32416).

      Control1..?
      72. ClinicalDocument.authorization.consent.statusCode
      Comments

      This consent SHALL contain exactly one [1..1] statusCode (CONF:1198-32417).

      74. ClinicalDocument.componentOf
      Comments

      SHOULD contain zero or one [0..1] componentOf (CONF:1198-30871).

      76. ClinicalDocument.componentOf.encompassingEncounter
      Comments

      The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-30872).

      Invariantsshould-id: SHOULD contain id (id.exists())
      78. ClinicalDocument.componentOf.encompassingEncounter.id
      ShortSG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
      Comments

      This encompassingEncounter SHOULD contain zero or more [0..*] id (CONF:1198-32395).

      80. ClinicalDocument.componentOf.encompassingEncounter.code
      Comments

      This encompassingEncounter SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Act Encounter Codes urn:oid:2.16.840.1.113762.1.4.1240.5 (CONF:1198-30873).

      Control1..?
      82. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant
      SlicingThis element introduces a set of slices on ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ typeCode
      • 84. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer
        Slice Namereferrer
        Comments

        This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:1198-30874) such that it

        Control0..1
        86. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:referrer.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="REF" Referrer (CONF:1198-30875).

        Fixed ValueREF
        88. ClinicalDocument.componentOf.encompassingEncounter.location
        Control1..?
        90. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility
        Comments

        Such locations SHALL contain exactly one [1..1] healthCareFacility (CONF:1198-30877).

        92. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.id
        Comments

        This healthCareFacility SHALL contain at least one [1..*] id (CONF:1198-30878).

        Control1..?
        94. ClinicalDocument.component
        Comments

        SHALL contain exactly one [1..1] component (CONF:1198-9588).

        96. ClinicalDocument.component.structuredBody
        Comments

        This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30352).

        Control1..?
        Invariantsap-or-a-and-p: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section. (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() or (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).count() = 2))
        ap-combo: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection')).empty())
        cc-rfv-combo: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present. (component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection')).exists() implies component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty())
        98. ClinicalDocument.component.structuredBody.component
        Control5..?
        SlicingThis element introduces a set of slices on ClinicalDocument.component.structuredBody.component. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • profile @ section
        • 100. ClinicalDocument.component.structuredBody.component:complications
          Slice Namecomplications
          Comments

          This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30353).

          Control1..1
          102. ClinicalDocument.component.structuredBody.component:complications.section
          Comments

          This component SHALL contain exactly one [1..1] Complications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.37:2024-05-01) (CONF:1198-30387).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Complications Section)
          104. ClinicalDocument.component.structuredBody.component:procedureDescription
          Slice NameprocedureDescription
          Comments

          This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30355) such that it

          Control1..1
          106. ClinicalDocument.component.structuredBody.component:procedureDescription.section
          Comments

          SHALL contain exactly one [1..1] Procedure Description Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.27) (CONF:1198-30356).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Description Section)
          108. ClinicalDocument.component.structuredBody.component:indications
          Slice Nameindications
          Comments

          This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30357) such that it

          Control1..1
          110. ClinicalDocument.component.structuredBody.component:indications.section
          Comments

          SHALL contain exactly one [1..1] Procedure Indications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.29:2014-06-09) (CONF:1198-30358).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Indications Section)
          112. ClinicalDocument.component.structuredBody.component:postProcedureDx
          Slice NamepostProcedureDx
          Comments

          This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30359) such that it

          Control1..1
          114. ClinicalDocument.component.structuredBody.component:postProcedureDx.section
          Comments

          SHALL contain exactly one [1..1] Postprocedure Diagnosis Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.36:2024-05-01) (CONF:1198-30360).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Postprocedure Diagnosis Section)
          116. ClinicalDocument.component.structuredBody.component:assessment
          Slice Nameassessment
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30361) such that it

          Control0..1
          118. ClinicalDocument.component.structuredBody.component:assessment.section
          Comments

          SHALL contain exactly one [1..1] Assessment Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.8) (CONF:1198-30362).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Assessment Section)
          120. ClinicalDocument.component.structuredBody.component:assessmentAndPlan
          Slice NameassessmentAndPlan
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30363) such that it

          Control0..1
          122. ClinicalDocument.component.structuredBody.component:assessmentAndPlan.section
          Comments

          SHALL contain exactly one [1..1] Assessment and Plan Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.9:2014-06-09) (CONF:1198-30364).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Assessment and Plan Section)
          124. ClinicalDocument.component.structuredBody.component:planOfTreatment
          Slice NameplanOfTreatment
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30365) such that it

          Control0..1
          126. ClinicalDocument.component.structuredBody.component:planOfTreatment.section
          Comments

          SHALL contain exactly one [1..1] Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30366).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Plan of Treatment Section)
          128. ClinicalDocument.component.structuredBody.component:allergies
          Slice Nameallergies
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30367) such that it

          Control0..1
          130. ClinicalDocument.component.structuredBody.component:allergies.section
          Comments

          SHALL contain exactly one [1..1] Allergies and Intolerances Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.6.1:2024-05-01) (CONF:1198-30368).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Allergies and Intolerances Section)
          132. ClinicalDocument.component.structuredBody.component:anesthesia
          Slice Nameanesthesia
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30369) such that it

          Control0..1
          134. ClinicalDocument.component.structuredBody.component:anesthesia.section
          Comments

          SHALL contain exactly one [1..1] Anesthesia Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.25:2014-06-09) (CONF:1198-30370).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Anesthesia Section)
          136. ClinicalDocument.component.structuredBody.component:chiefComplaint
          Slice NamechiefComplaint
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30371) such that it

          Control0..1
          138. ClinicalDocument.component.structuredBody.component:chiefComplaint.section
          Comments

          SHALL contain exactly one [1..1] Chief Complaint Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:1198-30372).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Chief Complaint Section)
          140. ClinicalDocument.component.structuredBody.component:chiefComplaintRFV
          Slice NamechiefComplaintRFV
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30373) such that it

          Control0..1
          142. ClinicalDocument.component.structuredBody.component:chiefComplaintRFV.section
          Comments

          SHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.13) (CONF:1198-30374).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Chief Complaint and Reason for Visit Section)
          144. ClinicalDocument.component.structuredBody.component:familyHistory
          Slice NamefamilyHistory
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30375) such that it

          Control0..1
          146. ClinicalDocument.component.structuredBody.component:familyHistory.section
          Comments

          SHALL contain exactly one [1..1] Family History Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.15:2024-05-01) (CONF:1198-30376).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Family History Section)
          148. ClinicalDocument.component.structuredBody.component:pastMedicalHistory
          Slice NamepastMedicalHistory
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30377) such that it

          Control0..1
          150. ClinicalDocument.component.structuredBody.component:pastMedicalHistory.section
          Comments

          SHALL contain exactly one [1..1] Past Medical History (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.20:2024-05-01) (CONF:1198-30378).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Past Medical History)
          152. ClinicalDocument.component.structuredBody.component:historyPresentIllness
          Slice NamehistoryPresentIllness
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30379) such that it

          Control0..1
          154. ClinicalDocument.component.structuredBody.component:historyPresentIllness.section
          Comments

          SHALL contain exactly one [1..1] History of Present Illness Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:1198-30380).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(History of Present Illness Section)
          156. ClinicalDocument.component.structuredBody.component:medicalHistory
          Slice NamemedicalHistory
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30381) such that it

          Control0..1
          158. ClinicalDocument.component.structuredBody.component:medicalHistory.section
          Comments

          SHALL contain exactly one [1..1] Medical (General) History Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.39) (CONF:1198-30382).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medical (General) History Section)
          160. ClinicalDocument.component.structuredBody.component:medications
          Slice Namemedications
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30383) such that it

          Control0..1
          162. ClinicalDocument.component.structuredBody.component:medications.section
          Comments

          SHALL contain exactly one [1..1] Medications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1.1:2014-06-09) (CONF:1198-30384).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medications Section)
          164. ClinicalDocument.component.structuredBody.component:medsAdministered
          Slice NamemedsAdministered
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30388) such that it

          Control0..1
          166. ClinicalDocument.component.structuredBody.component:medsAdministered.section
          Comments

          SHALL contain exactly one [1..1] Medications Administered Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.38:2014-06-09) (CONF:1198-30389).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medications Administered Section)
          168. ClinicalDocument.component.structuredBody.component:physicalExam
          Slice NamephysicalExam
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30390) such that it

          Control0..1
          170. ClinicalDocument.component.structuredBody.component:physicalExam.section
          Comments

          SHALL contain exactly one [1..1] Physical Exam Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.2.10:2024-05-01) (CONF:1198-30391).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Physical Exam Section)
          172. ClinicalDocument.component.structuredBody.component:plannedProcedure
          Slice NameplannedProcedure
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30392) such that it

          Control0..1
          174. ClinicalDocument.component.structuredBody.component:plannedProcedure.section
          Comments

          SHALL contain exactly one [1..1] Planned Procedure Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.30:2014-06-09) (CONF:1198-30393).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Planned Procedure Section)
          176. ClinicalDocument.component.structuredBody.component:procedureDisposition
          Slice NameprocedureDisposition
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30394) such that it

          Control0..1
          178. ClinicalDocument.component.structuredBody.component:procedureDisposition.section
          Comments

          SHALL contain exactly one [1..1] Procedure Disposition Section (identifier: urn:oid:2.16.840.1.113883.10.20.18.2.12) (CONF:1198-30395).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Disposition Section)
          180. ClinicalDocument.component.structuredBody.component:estBloodLoss
          Slice NameestBloodLoss
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30396) such that it

          Control0..1
          182. ClinicalDocument.component.structuredBody.component:estBloodLoss.section
          Comments

          SHALL contain exactly one [1..1] Procedure Estimated Blood Loss Section (identifier: urn:oid:2.16.840.1.113883.10.20.18.2.9) (CONF:1198-30397).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Estimated Blood Loss Section)
          184. ClinicalDocument.component.structuredBody.component:findings
          Slice Namefindings
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30398) such that it

          Control0..1
          186. ClinicalDocument.component.structuredBody.component:findings.section
          Comments

          SHALL contain exactly one [1..1] Procedure Findings Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.28:2024-05-01) (CONF:1198-30399).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Findings Section)
          188. ClinicalDocument.component.structuredBody.component:implants
          Slice Nameimplants
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30400) such that it

          Control0..1
          190. ClinicalDocument.component.structuredBody.component:implants.section
          Comments

          SHALL contain exactly one [1..1] Procedure Implants Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.40) (CONF:1198-30401).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Implants Section)
          192. ClinicalDocument.component.structuredBody.component:specimensTaken
          Slice NamespecimensTaken
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30402) such that it

          Control0..1
          194. ClinicalDocument.component.structuredBody.component:specimensTaken.section
          Comments

          SHALL contain exactly one [1..1] Procedure Specimens Taken Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.31) (CONF:1198-30403).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Specimens Taken Section)
          196. ClinicalDocument.component.structuredBody.component:procedures
          Slice Nameprocedures
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30404) such that it

          Control0..1
          198. ClinicalDocument.component.structuredBody.component:procedures.section
          Comments

          SHALL contain exactly one [1..1] Procedures Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09) (CONF:1198-30405).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedures Section)
          200. ClinicalDocument.component.structuredBody.component:reasonForVisit
          Slice NamereasonForVisit
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30406) such that it

          Control0..1
          202. ClinicalDocument.component.structuredBody.component:reasonForVisit.section
          Comments

          SHALL contain exactly one [1..1] Reason for Visit Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30407).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Reason for Visit Section)
          204. ClinicalDocument.component.structuredBody.component:reviewOfSystems
          Slice NamereviewOfSystems
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30408) such that it

          Control0..1
          206. ClinicalDocument.component.structuredBody.component:reviewOfSystems.section
          Comments

          SHALL contain exactly one [1..1] Review of Systems Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:1198-30409).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Review of Systems Section)
          208. ClinicalDocument.component.structuredBody.component:socialHistory
          Slice NamesocialHistory
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30410) such that it

          Control0..1
          210. ClinicalDocument.component.structuredBody.component:socialHistory.section
          Comments

          SHALL contain exactly one [1..1] Social History Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2024-05-01) (CONF:1198-30411).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Social History Section)
          212. ClinicalDocument.component.structuredBody.component:advDirectives
          Slice NameadvDirectives
          Comments

          This structuredBody MAY contain zero or one [0..1] component (CONF:1198-28942) such that it

          Control0..1
          214. ClinicalDocument.component.structuredBody.component:advDirectives.section
          Comments

          SHALL contain exactly one [1..1] Advance Directives Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.21.1:2024-05-01).

          Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Advance Directives Section)