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: Procedure Specimens Taken Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureSpecimensTakenSection Version: 4.0.0
Draft as of 2025-06-17 Computable Name: ProcedureSpecimensTakenSection
Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.31

The Procedure Specimens Taken Section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.

Usages:

Changes since version 3.0.0:

  • No changes

    • Formal Views of Template Content

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

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section Section XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root
    .... templateId:section 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.31
    ..... @extension 0..0
    ... code 1..1 CE Procedure specimens taken Narrative
    .... @code 1..1 cs Required Pattern: 59773-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST

    doco Documentation for this format
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:section 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.31
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Procedure specimens taken Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59773-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... entry 0..* Entry
    ... component 0..* InfrastructureRoot
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:section 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.31
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Procedure specimens taken Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59773-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... entry 0..* Entry
    ... component 0..* InfrastructureRoot
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()

    This structure is derived from Section

    Summary

    Mandatory: 8 elements
    Prohibited: 1 element

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of Section.templateId

    Differential View

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section Section XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root
    .... templateId:section 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.31
    ..... @extension 0..0
    ... code 1..1 CE Procedure specimens taken Narrative
    .... @code 1..1 cs Required Pattern: 59773-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST

    doco Documentation for this format

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:section 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.31
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Procedure specimens taken Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59773-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... entry 0..* Entry
    ... component 0..* InfrastructureRoot
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Section 1..1 Section XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:section 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.31
    ... @ID 0..1 xs:ID
    ... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
    Fixed Value: DOCSECT
    ... @moodCode 0..1 cs Binding: CDAActMood (required)
    Fixed Value: EVN
    ... id 0..1 II
    ... code 1..1 CE Procedure specimens taken Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59773-2
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... translation 0..* CD
    ... title 1..1 ST
    ... text 1..1 xhtml The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
    ... confidentialityCode 0..1 CE
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... author 0..* Author
    ... informant 0..* Informant
    ... entry 0..* Entry
    ... component 0..* InfrastructureRoot
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... realmCode 0..* CS
    .... typeId C 0..1 II Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Fixed Value: COMP
    .... @contextConductionInd 0..1 bl Fixed Value: true
    .... section 1..1 Section

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()

    This structure is derived from Section

    Summary

    Mandatory: 8 elements
    Prohibited: 1 element

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of Section.templateId

     

    Other representations of profile: CSV, Excel