Consolidated CDA (C-CDA)
3.0.0 - STU3 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 3.0.0 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 Indications Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureIndicationsSection Version: 3.0.0
Draft as of 2024-07-23 Computable Name: ProcedureIndicationsSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.29:2014-06-09

This section contains the reason(s) for the procedure or surgery. This section may include the preprocedure diagnoses as well as symptoms contributing to the reason for the procedure.

Usage:

Formal Views of Template Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.29
..... @extension 1..1 st Required Pattern: 2014-06-09
... code 1..1 CE Procedure indications [Interpretation] Narrative
.... @code 1..1 cs Required Pattern: 59768-2
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:indication 0..* Entry
..... observation 1..1 Indication Base for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.29
..... @extension 1..1 st Required Pattern: 2014-06-09
... code 1..1 CE Procedure indications [Interpretation] Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 59768-2
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:indication 0..* Entry
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
indication-valueerrorSection.entry:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
should-effectiveTimewarningSection.entry:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningSection.entry:indication.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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 0..1 II
.... @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: 2.16.840.1.113883.10.20.22.2.29
..... @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 Procedure indications [Interpretation] Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59768-2
.... @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
... 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 Slice: Unordered, Open by profile:observation
.... entry:indication 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @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 C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... 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 0..1 II
..... @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.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
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.entry:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:indication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:indication.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
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
indication-valueerrorSection.entry:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
should-effectiveTimewarningSection.entry:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningSection.entry:indication.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements(1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Section.templateId
  • The element 1 is sliced based on the value of Section.entry

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.29
..... @extension 1..1 st Required Pattern: 2014-06-09
... code 1..1 CE Procedure indications [Interpretation] Narrative
.... @code 1..1 cs Required Pattern: 59768-2
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:indication 0..* Entry
..... observation 1..1 Indication Base for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.29
..... @extension 1..1 st Required Pattern: 2014-06-09
... code 1..1 CE Procedure indications [Interpretation] Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 59768-2
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
.... entry:indication 0..* Entry
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
indication-valueerrorSection.entry:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
should-effectiveTimewarningSection.entry:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningSection.entry:indication.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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 0..1 II
.... @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: 2.16.840.1.113883.10.20.22.2.29
..... @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 Procedure indications [Interpretation] Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59768-2
.... @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
... 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 Slice: Unordered, Open by profile:observation
.... entry:indication 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @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 C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... 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 0..1 II
..... @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.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
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.entry:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:indication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:indication.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
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
indication-valueerrorSection.entry:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
should-effectiveTimewarningSection.entry:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningSection.entry:indication.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements(1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Section.templateId
  • The element 1 is sliced based on the value of Section.entry

 

Other representations of profile: CSV, Excel