Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 - Ballot 1
Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 - Ballot 1
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 5.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureSpecimensTakenSection | Version: 5.0.0-ballot | |||
| Draft as of 2025-11-24 | 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:
You can also check for usages in the FHIR IG Statistics
Changes since version 4.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Section |
Section | XML Namespace: urn:hl7-org:v3 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
   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 | ||
| 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). | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Section |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
 realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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 | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Section.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.templateId:section.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.classCode | Base | required | ActClassRecordOrganizer | 📦3.0.0 | THO v7.0 |
| Section.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Section.component.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.component.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Section |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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 | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Section.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.templateId:section.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.classCode | Base | required | ActClassRecordOrganizer | 📦3.0.0 | THO v7.0 |
| Section.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Section.component.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.component.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Section |
Section | XML Namespace: urn:hl7-org:v3 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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 | ||
| 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). | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Section |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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 | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Section.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.templateId:section.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.classCode | Base | required | ActClassRecordOrganizer | 📦3.0.0 | THO v7.0 |
| Section.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Section.component.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.component.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Section |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root | |
| 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 | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Section.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.templateId:section.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.classCode | Base | required | ActClassRecordOrganizer | 📦3.0.0 | THO v7.0 |
| Section.moodCode | Base | required | CDAActMood | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Section.component.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Section.component.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#5.0.0-ballot based on FHIR 5.0.0. Generated 2025-11-24
Links: Table of Contents |
QA Report
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