Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
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
| Draft as of 2024-11-24 |
Definitions for the ReviewofSystemsSection logical model.
Guidance on how to interpret the contents of this table can be found here
| 0. Section | |
| Logical Container | ClinicalDocument (CDA Class) |
| Validation | Instance of this type are validated by templateId |
| XML Format | In the XML format, this property has the namespace urn:hl7-org:v3. |
| 2. Section.templateId | |
| Control | 1..? |
| Slicing | This element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 4. Section.templateId:section | |
| Slice Name | section |
| Control | 1..1 |
| 6. Section.templateId:section.root | |
| Control | 1..? |
| Pattern Value | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
| 8. Section.templateId:section.extension | |
| Control | 0..0 |
| 10. Section.code | |
| Short | Review of systems Narrative - Reported |
| Control | 1..? |
| 12. Section.code.code | |
| Control | 1..? |
| Pattern Value | 10187-3 |
| 14. Section.code.codeSystem | |
| Control | 1..? |
| Pattern Value | 2.16.840.1.113883.6.1 |
| 16. Section.title | |
| Control | 1..? |
| 18. Section.text | |
| Control | 1..? |
Guidance on how to interpret the contents of this table can be found here
| 0. Section | |
| Definition | Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. Base definition for all types defined in FHIR type system. |
| Short | Base for all types and resources |
| Control | 10..1* |
| Is Modifier | false |
| Logical Container | ClinicalDocument (CDA Class) |
| Validation | Instance of this type are validated by templateId |
| XML Format | In the XML format, this property has the namespace urn:hl7-org:v3. |
| 2. Section.templateId | |
| Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
| Control | 1..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| Slicing | This element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 4. Section.templateId:section | |
| Slice Name | section |
| Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
| Control | 1..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| 6. Section.templateId:section.root | |
| Definition | A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. |
| Control | 1..1 |
| Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Root |
| Pattern Value | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
| 8. Section.templateId:section.extension | |
| Definition | A character string as a unique identifier within the scope of the identifier root. |
| Control | 0..0 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Extension |
| 10. Section.code | |
| Short | Review of systems Narrative - Reported |
| Control | 1..1 |
| Binding | For example codes, see DocumentSectionType (example to http://terminology.hl7.org/ValueSet/v3-DocumentSectionType) |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
| 12. Section.code.code | |
| Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
| Control | 1..1 |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Code |
| Pattern Value | 10187-3 |
| 14. Section.code.codeSystem | |
| Definition | Specifies the code system that defines the code. |
| Control | 1..1 |
| Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Code System |
| Pattern Value | 2.16.840.1.113883.6.1 |
| 16. Section.code.qualifier | |
| Definition | Specifies additional codes that increase the specificity of the the primary code. |
| Control | 0..0 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CR |
| Label | Qualifier |
| 18. Section.title | |
| Control | 1..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
| 20. Section.text | |
| Control | 1..1 |
| Type | xhtml |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | This property is represented as CDA Text in the XML. |
Guidance on how to interpret the contents of this table can be found here
| 0. Section | |
| Definition | Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. |
| Short | Base for all types and resources |
| Control | 1..1 |
| Is Modifier | false |
| Logical Container | ClinicalDocument (CDA Class) |
| Validation | Instance of this type are validated by templateId |
| XML Format | In the XML format, this property has the namespace urn:hl7-org:v3. |
| 2. Section.nullFlavor | |
| Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Exceptional Value Detail |
| 4. Section.realmCode | |
| Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
| 6. Section.typeId | |
| Definition | When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question. |
| Control | 0..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| 8. Section.typeId.nullFlavor | |
| Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Exceptional Value Detail |
| 10. Section.typeId.assigningAuthorityName | |
| Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Assigning Authority Name |
| 12. Section.typeId.displayable | |
| Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
| Control | 0..1 |
| Type | boolean(bl: Boolean) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Displayable |
| 14. Section.typeId.root | |
| Definition | Identifies the type as an HL7 Registered model |
| Control | 1..1 |
| Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Root |
| Fixed Value | 2.16.840.1.113883.1.3 |
| 16. Section.typeId.extension | |
| Definition | A character string as a unique identifier within the scope of the identifier root. |
| Control | 1..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Extension |
| 18. Section.templateId | |
| Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
| Control | 1..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| Slicing | This element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 20. Section.templateId:section | |
| Slice Name | section |
| Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
| Control | 1..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| 22. Section.templateId:section.nullFlavor | |
| Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Exceptional Value Detail |
| 24. Section.templateId:section.assigningAuthorityName | |
| Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Assigning Authority Name |
| 26. Section.templateId:section.displayable | |
| Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
| Control | 0..1 |
| Type | boolean(bl: Boolean) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Displayable |
| 28. Section.templateId:section.root | |
| Definition | A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. |
| Control | 1..1 |
| Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Root |
| Pattern Value | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
| 30. Section.templateId:section.extension | |
| Definition | A character string as a unique identifier within the scope of the identifier root. |
| Control | 0..0 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Extension |
| 32. Section.ID | |
| Control | 0..1 |
| Type | id(xs:ID) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| 34. Section.classCode | |
| Control | 0..1 |
| Binding | The codes SHALL be taken from ActClassRecordOrganizer (required to http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Fixed Value | DOCSECT |
| 36. Section.moodCode | |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDAActMood (required to http://hl7.org/cda/stds/core/ValueSet/CDAActMood) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Fixed Value | EVN |
| 38. Section.id | |
| Control | 0..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| 40. Section.code | |
| Short | Review of systems Narrative - Reported |
| Control | 1..1 |
| Binding | For example codes, see DocumentSectionType (example to http://terminology.hl7.org/ValueSet/v3-DocumentSectionType) |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
| 42. Section.code.nullFlavor | |
| Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Exceptional Value Detail |
| 44. Section.code.code | |
| Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
| Control | 1..1 |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Code |
| Pattern Value | 10187-3 |
| 46. Section.code.codeSystem | |
| Definition | Specifies the code system that defines the code. |
| Control | 1..1 |
| Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Code System |
| Pattern Value | 2.16.840.1.113883.6.1 |
| 48. Section.code.codeSystemName | |
| Definition | The common name of the coding system. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Code System Name |
| 50. Section.code.codeSystemVersion | |
| Definition | If applicable, a version descriptor defined specifically for the given code system. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Code System Version |
| 52. Section.code.displayName | |
| Definition | A name or title for the code, under which the sending system shows the code value to its users. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Display Name |
| 54. Section.code.sdtcValueSet | |
| Definition | The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept. |
| Control | 0..1 |
| Type | string(oid: ISO Object Identifier) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet. |
| 56. Section.code.sdtcValueSetVersion | |
| Definition | The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion. |
| 58. Section.code.originalText | |
| Definition | The text or phrase used as the basis for the coding. |
| Control | 0..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/ED |
| Label | Original Text |
| 60. Section.code.qualifier | |
| Definition | Specifies additional codes that increase the specificity of the the primary code. |
| Control | 0..0 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CR |
| Label | Qualifier |
| 62. Section.code.translation | |
| Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CD |
| XML Format | The type of this property is determined using the xsi:typeattribute. |
| Label | Translation |
| 64. Section.title | |
| Control | 1..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
| 66. Section.text | |
| Control | 1..1 |
| Type | xhtml |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | This property is represented as CDA Text in the XML. |
| 68. Section.confidentialityCode | |
| Control | 0..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
| 70. Section.languageCode | |
| Control | 0..1 |
| Binding | The codes SHALL be taken from AllLanguages (required to http://hl7.org/fhir/ValueSet/all-languages) |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
| 72. Section.subject | |
| Control | 0..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Subject |
| 74. Section.author | |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Author |
| 76. Section.informant | |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Informant |
| 78. Section.entry | |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Entry |
| 80. Section.component | |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot |
| 82. Section.component.nullFlavor | |
| Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Exceptional Value Detail |
| 84. Section.component.realmCode | |
| Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
| 86. Section.component.typeId | |
| Definition | When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question. |
| Control | 0..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| 88. Section.component.typeId.nullFlavor | |
| Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
| Control | 0..1 |
| Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor) |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Exceptional Value Detail |
| 90. Section.component.typeId.assigningAuthorityName | |
| Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
| Control | 0..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Assigning Authority Name |
| 92. Section.component.typeId.displayable | |
| Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
| Control | 0..1 |
| Type | boolean(bl: Boolean) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Displayable |
| 94. Section.component.typeId.root | |
| Definition | Identifies the type as an HL7 Registered model |
| Control | 1..1 |
| Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Root |
| Fixed Value | 2.16.840.1.113883.1.3 |
| 96. Section.component.typeId.extension | |
| Definition | A character string as a unique identifier within the scope of the identifier root. |
| Control | 1..1 |
| Type | string(st: Character String) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Label | Extension |
| 98. Section.component.templateId | |
| Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
| Control | 0..* |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
| 100. Section.component.typeCode | |
| Definition | Drawn from concept domain DocumentSectionType |
| Control | 0..1 |
| Type | code(cs: Coded Simple Value) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Fixed Value | COMP |
| 102. Section.component.contextConductionInd | |
| Control | 0..1 |
| Type | boolean(bl: Boolean) |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| XML Format | In the XML format, this property is represented as an attribute. |
| Fixed Value | true |
| 104. Section.component.section | |
| Control | 1..1 |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Section |
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