Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection | Version: 4.0.0-ballot | |||
| Draft as of 2024-12-19 | Computable Name: ProceduresSection | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09 | ||||
This section describes all historical or current interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized.
Subsections MAY be used to partition the entries into different categories. For example, a subsection with the Loinc code of 18748-4 (Diagnostic Imaging) MAY be used to group DI procedures. Similarly 11502-2 (Clinical Laboratory) MAY be used to group laboratory procedures.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Section |
C | 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) shall-procedure-act-procedure: If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure |
  @nullFlavor |
0..1 | cs | If a required section contains no information, the @nullFlavor MAY be set to NI 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 | ||
 Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
  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: 2.16.840.1.113883.10.20.22.2.7.1 | |
 @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @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 | History of Procedures Document | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 47519-4 | |
| @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 | ||
| confidentialityCode |
0..1 | CE | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| Slices for entry |
0..* | Entry | If section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09) Slice: Unordered, Open by profile:procedure | |
| entry:entryProcedure |
0..* | Entry | ||
| @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 |
0..1 | cs | Binding: x_ActRelationshipEntry (required) | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
C | 1..1 | ProcedureActivityProcedure | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value active-high-ts-after-document: If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime should-targetSiteCode: SHOULD contain targetSiteCode should-performer: SHOULD contain performer should-author: SHOULD contain author |
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
 component |
0..* | InfrastructureRoot | ||
| @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 |
0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |
| section |
1..1 | Section | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:entryProcedure.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:entryProcedure.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:entryProcedure.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| II-1 | error | Section.typeId, Section.entry:entryProcedure.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| active-high-ts-after-document | error | Section.entry:entryProcedure.procedure | If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime : (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value | |
| shall-procedure-act-procedure | error | Section | If section/@nullFlavor is not present, SHALL contain at least one Procedure Activity Procedure : nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure')).exists() | |
| should-author | warning | Section.entry:entryProcedure.procedure | SHOULD contain author : author.exists() | |
| should-performer | warning | Section.entry:entryProcedure.procedure | SHOULD contain performer : performer.exists() | |
| should-targetSiteCode | warning | Section.entry:entryProcedure.procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Section.entry:entryProcedure.procedure | SHOULD contain text/reference/@value : text.reference.value.exists() |
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-12-19
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