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
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection | Version: 4.0.0 | |||
Draft as of 2025-10-02 | Computable Name: SocialHistorySection | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2015-08-01 |
This section contains social history data that influence a patient's physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header. Mental/behavioral health assessments such as PHQ-9 (Patient Health Questionnaire-9) for depression screening are captured in the Mental Status section.
Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:
Recommended Entries: SmokingStatus
Optional Entries: CaregiverCharacteristics, CharacteristicsofHomeEnvironment, CulturalandReligiousObservation, PregnancyIntentionInNextYear, PregnancyStatusObservation, SocialHistoryObservation
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 3.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Id | Grade | Path(s) | Description | Expression |
should-smoking-status | warning | Section | SHOULD contain Smoking Status |
entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
|
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 v6.5 |
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.entry:socialHistory.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyPregnancy.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:smokingStatus.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:caregiver.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:culturalReligious.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:homeCharacteristics.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyIntention.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
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.entry:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
should-smoking-status | warning | Section | SHOULD contain Smoking Status |
entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
|
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 v6.5 |
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.entry:socialHistory.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyPregnancy.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:smokingStatus.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:caregiver.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:culturalReligious.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:homeCharacteristics.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyIntention.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
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.entry:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
should-smoking-status | warning | Section | SHOULD contain Smoking Status |
entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
|
This structure is derived from Section
Summary
Mandatory: 9 elements(7 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Section
Id | Grade | Path(s) | Description | Expression |
should-smoking-status | warning | Section | SHOULD contain Smoking Status |
entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
|
Key Elements View
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 v6.5 |
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.entry:socialHistory.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyPregnancy.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:smokingStatus.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:caregiver.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:culturalReligious.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:homeCharacteristics.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyIntention.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
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.entry:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
should-smoking-status | warning | Section | SHOULD contain Smoking Status |
entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
|
Snapshot View
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 v6.5 |
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.entry:socialHistory.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:socialHistory.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyPregnancy.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyPregnancy.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:smokingStatus.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:smokingStatus.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:caregiver.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:caregiver.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:culturalReligious.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:culturalReligious.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:homeCharacteristics.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:homeCharacteristics.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
Section.entry:pregnancyIntention.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
Section.entry:pregnancyIntention.​typeCode | Base | required | x_ActRelationshipEntry | 📦3.0.0 | THO v6.5 |
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.entry:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
should-smoking-status | warning | Section | SHOULD contain Smoking Status |
entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
|
This structure is derived from Section
Summary
Mandatory: 9 elements(7 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: