C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot United States of America flag

C-CDA on FHIR, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ccda-on-fhir/ and changes regularly. See the Directory of published versions

Resource Profile: Consultation Note

Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note Version: 2.0.0-ballot
Standards status: Trial-use Computable Name: ConsultationNote

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.

A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).

2025 Ballot of C-CDA ↔ FHIR US Core Mapping

The current release of this IG adds relevant mapping content from C-CDA ↔ FHIR mapping project which was related to the original C-CDA on FHIR work. These mappings are included under the "Mapping" heading and will undergo future updates for additional content.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* USRealmHeader A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language S 1..1 code language
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... Slices for extension Content/Rules for all slices
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Consultation Note
Binding: ConsultDocumentType (required)
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 1..1 Reference(US Core Encounter Profile) encompassingEncounter
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... attester:legal_attester S 0..1 BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian
... Slices for section C 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... section:allergies_and_intolerances_section SC 1..1 BackboneElement Allergies and Intolerances Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Allergies and adverse reactions
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
.... section:history_of_present_illness_section SC 1..1 BackboneElement History of Present Illness Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept History of present illness
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:problem_section C 1..1 BackboneElement Problem Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Problem list
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry SC 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:medications_section C 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medication use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) A reference to data that supports this section
.... section:physical_exam_section C 0..1 BackboneElement Physical Exam Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:results_section C 0..1 BackboneElement Results Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Relevant diagnostic tests/laboratory data
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Laboratory Result Observation Profile) A reference to data that supports this section
.... section:advance_directives_section SC 0..1 BackboneElement Advance Directives Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Advance directives
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry SC 0..* Reference(Consent) A reference to data that supports this section
.... section:assessment_and_plan_section C 0..1 BackboneElement Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessment (evaluation) and plan
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile | Observation | Communication) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:assessment_section C 0..1 BackboneElement Assessment Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessments (evaluation)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:chief_complaint_and_reason_for_visit_section C 0..1 BackboneElement Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint and reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:chief_complaint_section C 0..1 BackboneElement Chief Complaint Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:family_history_section C 0..1 BackboneElement Family History Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Family history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(FamilyMemberHistory) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:functional_status_section C 0..1 BackboneElement Functional Status Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Functional status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:general_status_section C 0..1 BackboneElement General Status Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings of General status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:past_medical_history_section C 0..1 BackboneElement Past Medical History Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Past Medical History
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:immunizations_section C 0..1 BackboneElement Immunizations Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of immunization
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:medical_equipment_section C 0..1 BackboneElement Medical Equipment Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medical device use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry SC 0..* Reference(Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:mental_status_section C 0..1 BackboneElement Mental Status Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Mental status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:nutrition_section C 0..1 BackboneElement Nutrition Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Diet and nutrition
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(NutritionOrder | ClinicalImpression) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:plan_of_treatment_section C 0..1 BackboneElement Plan of Treatment Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Plan of treatment
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:procedures_section C 0..1 BackboneElement Procedures Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of Procedures
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:reason_for_visit_section C 0..1 BackboneElement Reason for Visit Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:review_of_systems_section C 0..1 BackboneElement Review of Systems Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Review of systems
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:social_history_section C 0..1 BackboneElement Social History Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Social history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Smoking Status Observation Profile) Smoking status
.... section:vital_signs_section C 0..1 BackboneElement Vital Signs Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Vital signs
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Vital Signs Profile) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
From this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.codeexamplePattern Value: LOINC Code 48765-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:history_of_present_illness_section.codeexamplePattern Value: LOINC Code 10164-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:problem_section.codeexamplePattern Value: LOINC Code 11450-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medications_section.codeexamplePattern Value: LOINC Code 10160-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:physical_exam_section.codeexamplePattern Value: LOINC Code 29545-1
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:results_section.codeexamplePattern Value: LOINC Code 30954-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:advance_directives_section.codeexamplePattern Value: LOINC Code 42348-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_and_plan_section.codeexamplePattern Value: LOINC Code 51847-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_section.codeexamplePattern Value: LOINC Code 51848-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.codeexamplePattern Value: LOINC Code 46239-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_section.codeexamplePattern Value: LOINC Code 10154-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:family_history_section.codeexamplePattern Value: LOINC Code 10157-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:functional_status_section.codeexamplePattern Value: LOINC Code 47420-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:general_status_section.codeexamplePattern Value: LOINC Code 10210-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:past_medical_history_section.codeexamplePattern Value: LOINC Code 11348-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:immunizations_section.codeexamplePattern Value: LOINC Code 11369-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medical_equipment_section.codeexamplePattern Value: LOINC Code 46264-8
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:mental_status_section.codeexamplePattern Value: LOINC Code 10190-7
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:nutrition_section.codeexamplePattern Value: LOINC Code 61144-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:plan_of_treatment_section.codeexamplePattern Value: LOINC Code 18776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:procedures_section.codeexamplePattern Value: LOINC Code 47519-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:reason_for_visit_section.codeexamplePattern Value: LOINC Code 29299-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:review_of_systems_section.codeexamplePattern Value: LOINC Code 10187-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:social_history_section.codeexamplePattern Value: LOINC Code 29762-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:vital_signs_section.codeexamplePattern Value: LOINC Code 8716-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* USRealmHeader A set of resources composed into a single coherent clinical statement with clinical attestation
... type S 1..1 CodeableConcept Consultation Note
Binding: ConsultDocumentType (required)
... encounter S 1..1 Reference(US Core Encounter Profile) encompassingEncounter
... Slices for section 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:allergies_and_intolerances_section S 1..1 BackboneElement Allergies and Intolerances Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Allergies and adverse reactions
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
..... text S 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry S 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
.... section:history_of_present_illness_section S 1..1 BackboneElement History of Present Illness Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept History of present illness
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
..... text S 1..1 Narrative This section contains only human readable content
.... section:problem_section 1..1 BackboneElement Problem Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Problem list
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
..... text 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry S 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:medications_section 0..1 BackboneElement Medications Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medication use
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) A reference to data that supports this section
.... section:physical_exam_section 0..1 BackboneElement Physical Exam Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:results_section 0..1 BackboneElement Results Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Relevant diagnostic tests/laboratory data
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Laboratory Result Observation Profile) A reference to data that supports this section
.... section:advance_directives_section S 0..1 BackboneElement Advance Directives Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Advance directives
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
..... text S 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry S 0..* Reference(Consent) A reference to data that supports this section
.... section:assessment_and_plan_section 0..1 BackboneElement Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessment (evaluation) and plan
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Condition Profile | Observation | Communication) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:assessment_section 0..1 BackboneElement Assessment Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessments (evaluation)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
..... text 1..1 Narrative This section contains only human readable content
.... section:chief_complaint_and_reason_for_visit_section 0..1 BackboneElement Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint and reason for visit
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
..... text 1..1 Narrative This section contains only human readable content
.... section:chief_complaint_section 0..1 BackboneElement Chief Complaint Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
..... text 1..1 Narrative This section contains only human readable content
.... section:family_history_section 0..1 BackboneElement Family History Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Family history
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(FamilyMemberHistory) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:functional_status_section 0..1 BackboneElement Functional Status Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Functional status
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:general_status_section 0..1 BackboneElement General Status Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings of General status
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
..... text 1..1 Narrative This section contains only human readable content
.... section:past_medical_history_section 0..1 BackboneElement Past Medical History Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Past Medical History
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:immunizations_section 0..1 BackboneElement Immunizations Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of immunization
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:medical_equipment_section 0..1 BackboneElement Medical Equipment Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medical device use
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry S 0..* Reference(Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:mental_status_section 0..1 BackboneElement Mental Status Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Mental status
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:nutrition_section 0..1 BackboneElement Nutrition Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Diet and nutrition
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(NutritionOrder | ClinicalImpression) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:plan_of_treatment_section 0..1 BackboneElement Plan of Treatment Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Plan of treatment
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:procedures_section 0..1 BackboneElement Procedures Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of Procedures
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:reason_for_visit_section 0..1 BackboneElement Reason for Visit Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Reason for visit
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
..... text 1..1 Narrative This section contains only human readable content
.... section:review_of_systems_section 0..1 BackboneElement Review of Systems Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Review of systems
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... text 1..1 Narrative This section contains only human readable content
.... section:social_history_section 0..1 BackboneElement Social History Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Social history
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Smoking Status Observation Profile) Smoking status
.... section:vital_signs_section 0..1 BackboneElement Vital Signs Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Vital signs
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Vital Signs Profile) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
From this IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* USRealmHeader A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Consultation Note
Binding: ConsultDocumentType (required)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 1..1 Reference(US Core Encounter Profile) encompassingEncounter
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement attester
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section C 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 0..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:allergies_and_intolerances_section SC 1..1 BackboneElement Allergies and Intolerances Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Allergies and adverse reactions
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:history_of_present_illness_section SC 1..1 BackboneElement History of Present Illness Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept History of present illness
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:problem_section C 1..1 BackboneElement Problem Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Problem list
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry SC 0..* Reference(US Core Condition Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:medications_section C 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medication use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:physical_exam_section C 0..1 BackboneElement Physical Exam Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:results_section C 0..1 BackboneElement Results Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Relevant diagnostic tests/laboratory data
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Laboratory Result Observation Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:advance_directives_section SC 0..1 BackboneElement Advance Directives Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Advance directives
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry SC 0..* Reference(Consent) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:assessment_and_plan_section C 0..1 BackboneElement Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessment (evaluation) and plan
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile | Observation | Communication) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:assessment_section C 0..1 BackboneElement Assessment Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessments (evaluation)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:chief_complaint_and_reason_for_visit_section C 0..1 BackboneElement Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint and reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:chief_complaint_section C 0..1 BackboneElement Chief Complaint Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:family_history_section C 0..1 BackboneElement Family History Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Family history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(FamilyMemberHistory) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:functional_status_section C 0..1 BackboneElement Functional Status Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Functional status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:general_status_section C 0..1 BackboneElement General Status Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings of General status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:past_medical_history_section C 0..1 BackboneElement Past Medical History Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Past Medical History
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:immunizations_section C 0..1 BackboneElement Immunizations Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of immunization
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:medical_equipment_section C 0..1 BackboneElement Medical Equipment Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medical device use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry SC 0..* Reference(Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:mental_status_section C 0..1 BackboneElement Mental Status Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Mental status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:nutrition_section C 0..1 BackboneElement Nutrition Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Diet and nutrition
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(NutritionOrder | ClinicalImpression) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:plan_of_treatment_section C 0..1 BackboneElement Plan of Treatment Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Plan of treatment
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:procedures_section C 0..1 BackboneElement Procedures Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of Procedures
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:reason_for_visit_section C 0..1 BackboneElement Reason for Visit Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:review_of_systems_section C 0..1 BackboneElement Review of Systems Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Review of systems
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:social_history_section C 0..1 BackboneElement Social History Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Social history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Smoking Status Observation Profile) Smoking status
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:vital_signs_section C 0..1 BackboneElement Vital Signs Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Vital signs
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Vital Signs Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
From this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
From the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.codeexamplePattern Value: LOINC Code 48765-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:history_of_present_illness_section.codeexamplePattern Value: LOINC Code 10164-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:history_of_present_illness_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:history_of_present_illness_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:history_of_present_illness_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:problem_section.codeexamplePattern Value: LOINC Code 11450-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:problem_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:problem_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:problem_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:medications_section.codeexamplePattern Value: LOINC Code 10160-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medications_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:medications_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:medications_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:physical_exam_section.codeexamplePattern Value: LOINC Code 29545-1
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:physical_exam_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:physical_exam_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:physical_exam_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:results_section.codeexamplePattern Value: LOINC Code 30954-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:results_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:results_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:results_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:advance_directives_section.codeexamplePattern Value: LOINC Code 42348-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:advance_directives_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:advance_directives_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:advance_directives_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:assessment_and_plan_section.codeexamplePattern Value: LOINC Code 51847-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_and_plan_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:assessment_and_plan_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:assessment_and_plan_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:assessment_section.codeexamplePattern Value: LOINC Code 51848-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:assessment_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:assessment_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.codeexamplePattern Value: LOINC Code 46239-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:chief_complaint_section.codeexamplePattern Value: LOINC Code 10154-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:chief_complaint_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:chief_complaint_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:family_history_section.codeexamplePattern Value: LOINC Code 10157-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:family_history_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:family_history_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:family_history_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:functional_status_section.codeexamplePattern Value: LOINC Code 47420-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:functional_status_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:functional_status_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:functional_status_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:general_status_section.codeexamplePattern Value: LOINC Code 10210-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:general_status_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:general_status_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:general_status_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:past_medical_history_section.codeexamplePattern Value: LOINC Code 11348-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:past_medical_history_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:past_medical_history_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:past_medical_history_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:immunizations_section.codeexamplePattern Value: LOINC Code 11369-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:immunizations_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:immunizations_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:immunizations_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:medical_equipment_section.codeexamplePattern Value: LOINC Code 46264-8
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medical_equipment_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:medical_equipment_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:medical_equipment_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:mental_status_section.codeexamplePattern Value: LOINC Code 10190-7
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:mental_status_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:mental_status_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:mental_status_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:nutrition_section.codeexamplePattern Value: LOINC Code 61144-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:nutrition_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:nutrition_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:nutrition_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:plan_of_treatment_section.codeexamplePattern Value: LOINC Code 18776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:plan_of_treatment_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:plan_of_treatment_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:plan_of_treatment_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:procedures_section.codeexamplePattern Value: LOINC Code 47519-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:procedures_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:procedures_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:procedures_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:reason_for_visit_section.codeexamplePattern Value: LOINC Code 29299-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:reason_for_visit_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:reason_for_visit_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:reason_for_visit_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:review_of_systems_section.codeexamplePattern Value: LOINC Code 10187-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:review_of_systems_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:review_of_systems_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:review_of_systems_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:social_history_section.codeexamplePattern Value: LOINC Code 29762-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:social_history_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:social_history_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:social_history_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:vital_signs_section.codeexamplePattern Value: LOINC Code 8716-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:vital_signs_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:vital_signs_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:vital_signs_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* USRealmHeader A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language S 1..1 code language
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... Slices for extension Content/Rules for all slices
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Consultation Note
Binding: ConsultDocumentType (required)
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 1..1 Reference(US Core Encounter Profile) encompassingEncounter
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... attester:legal_attester S 0..1 BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian
... Slices for section C 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... section:allergies_and_intolerances_section SC 1..1 BackboneElement Allergies and Intolerances Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Allergies and adverse reactions
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
.... section:history_of_present_illness_section SC 1..1 BackboneElement History of Present Illness Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept History of present illness
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:problem_section C 1..1 BackboneElement Problem Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Problem list
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry SC 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:medications_section C 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medication use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) A reference to data that supports this section
.... section:physical_exam_section C 0..1 BackboneElement Physical Exam Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:results_section C 0..1 BackboneElement Results Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Relevant diagnostic tests/laboratory data
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Laboratory Result Observation Profile) A reference to data that supports this section
.... section:advance_directives_section SC 0..1 BackboneElement Advance Directives Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Advance directives
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry SC 0..* Reference(Consent) A reference to data that supports this section
.... section:assessment_and_plan_section C 0..1 BackboneElement Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessment (evaluation) and plan
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile | Observation | Communication) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:assessment_section C 0..1 BackboneElement Assessment Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessments (evaluation)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:chief_complaint_and_reason_for_visit_section C 0..1 BackboneElement Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint and reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:chief_complaint_section C 0..1 BackboneElement Chief Complaint Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:family_history_section C 0..1 BackboneElement Family History Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Family history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(FamilyMemberHistory) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:functional_status_section C 0..1 BackboneElement Functional Status Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Functional status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:general_status_section C 0..1 BackboneElement General Status Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings of General status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:past_medical_history_section C 0..1 BackboneElement Past Medical History Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Past Medical History
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:immunizations_section C 0..1 BackboneElement Immunizations Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of immunization
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:medical_equipment_section C 0..1 BackboneElement Medical Equipment Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medical device use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry SC 0..* Reference(Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:mental_status_section C 0..1 BackboneElement Mental Status Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Mental status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:nutrition_section C 0..1 BackboneElement Nutrition Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Diet and nutrition
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(NutritionOrder | ClinicalImpression) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:plan_of_treatment_section C 0..1 BackboneElement Plan of Treatment Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Plan of treatment
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:procedures_section C 0..1 BackboneElement Procedures Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of Procedures
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:reason_for_visit_section C 0..1 BackboneElement Reason for Visit Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:review_of_systems_section C 0..1 BackboneElement Review of Systems Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Review of systems
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:social_history_section C 0..1 BackboneElement Social History Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Social history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Smoking Status Observation Profile) Smoking status
.... section:vital_signs_section C 0..1 BackboneElement Vital Signs Section
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Vital signs
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Vital Signs Profile) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
From this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.codeexamplePattern Value: LOINC Code 48765-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:history_of_present_illness_section.codeexamplePattern Value: LOINC Code 10164-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:problem_section.codeexamplePattern Value: LOINC Code 11450-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medications_section.codeexamplePattern Value: LOINC Code 10160-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:physical_exam_section.codeexamplePattern Value: LOINC Code 29545-1
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:results_section.codeexamplePattern Value: LOINC Code 30954-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:advance_directives_section.codeexamplePattern Value: LOINC Code 42348-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_and_plan_section.codeexamplePattern Value: LOINC Code 51847-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_section.codeexamplePattern Value: LOINC Code 51848-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.codeexamplePattern Value: LOINC Code 46239-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_section.codeexamplePattern Value: LOINC Code 10154-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:family_history_section.codeexamplePattern Value: LOINC Code 10157-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:functional_status_section.codeexamplePattern Value: LOINC Code 47420-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:general_status_section.codeexamplePattern Value: LOINC Code 10210-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:past_medical_history_section.codeexamplePattern Value: LOINC Code 11348-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:immunizations_section.codeexamplePattern Value: LOINC Code 11369-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medical_equipment_section.codeexamplePattern Value: LOINC Code 46264-8
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:mental_status_section.codeexamplePattern Value: LOINC Code 10190-7
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:nutrition_section.codeexamplePattern Value: LOINC Code 61144-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:plan_of_treatment_section.codeexamplePattern Value: LOINC Code 18776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:procedures_section.codeexamplePattern Value: LOINC Code 47519-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:reason_for_visit_section.codeexamplePattern Value: LOINC Code 29299-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:review_of_systems_section.codeexamplePattern Value: LOINC Code 10187-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:social_history_section.codeexamplePattern Value: LOINC Code 29762-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:vital_signs_section.codeexamplePattern Value: LOINC Code 8716-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* USRealmHeader A set of resources composed into a single coherent clinical statement with clinical attestation
... type S 1..1 CodeableConcept Consultation Note
Binding: ConsultDocumentType (required)
... encounter S 1..1 Reference(US Core Encounter Profile) encompassingEncounter
... Slices for section 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:allergies_and_intolerances_section S 1..1 BackboneElement Allergies and Intolerances Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Allergies and adverse reactions
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
..... text S 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry S 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
.... section:history_of_present_illness_section S 1..1 BackboneElement History of Present Illness Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept History of present illness
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
..... text S 1..1 Narrative This section contains only human readable content
.... section:problem_section 1..1 BackboneElement Problem Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Problem list
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
..... text 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry S 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:medications_section 0..1 BackboneElement Medications Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medication use
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) A reference to data that supports this section
.... section:physical_exam_section 0..1 BackboneElement Physical Exam Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:results_section 0..1 BackboneElement Results Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Relevant diagnostic tests/laboratory data
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Laboratory Result Observation Profile) A reference to data that supports this section
.... section:advance_directives_section S 0..1 BackboneElement Advance Directives Section
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Advance directives
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
..... text S 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry S 0..* Reference(Consent) A reference to data that supports this section
.... section:assessment_and_plan_section 0..1 BackboneElement Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessment (evaluation) and plan
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Condition Profile | Observation | Communication) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:assessment_section 0..1 BackboneElement Assessment Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessments (evaluation)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
..... text 1..1 Narrative This section contains only human readable content
.... section:chief_complaint_and_reason_for_visit_section 0..1 BackboneElement Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint and reason for visit
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
..... text 1..1 Narrative This section contains only human readable content
.... section:chief_complaint_section 0..1 BackboneElement Chief Complaint Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
..... text 1..1 Narrative This section contains only human readable content
.... section:family_history_section 0..1 BackboneElement Family History Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Family history
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(FamilyMemberHistory) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:functional_status_section 0..1 BackboneElement Functional Status Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Functional status
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:general_status_section 0..1 BackboneElement General Status Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings of General status
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
..... text 1..1 Narrative This section contains only human readable content
.... section:past_medical_history_section 0..1 BackboneElement Past Medical History Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Past Medical History
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Condition Profile) A reference to data that supports this section
.... section:immunizations_section 0..1 BackboneElement Immunizations Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of immunization
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:medical_equipment_section 0..1 BackboneElement Medical Equipment Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medical device use
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry S 0..* Reference(Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:mental_status_section 0..1 BackboneElement Mental Status Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Mental status
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:nutrition_section 0..1 BackboneElement Nutrition Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Diet and nutrition
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(NutritionOrder | ClinicalImpression) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:plan_of_treatment_section 0..1 BackboneElement Plan of Treatment Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Plan of treatment
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:procedures_section 0..1 BackboneElement Procedures Section
..... title 1..1 string title
..... code 1..1 CodeableConcept History of Procedures
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:reason_for_visit_section 0..1 BackboneElement Reason for Visit Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Reason for visit
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
..... text 1..1 Narrative This section contains only human readable content
.... section:review_of_systems_section 0..1 BackboneElement Review of Systems Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Review of systems
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... text 1..1 Narrative This section contains only human readable content
.... section:social_history_section 0..1 BackboneElement Social History Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Social history
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(US Core Smoking Status Observation Profile) Smoking status
.... section:vital_signs_section 0..1 BackboneElement Vital Signs Section
..... title 1..1 string title
..... code 1..1 CodeableConcept Vital signs
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
..... text 1..1 Narrative text
..... Slices for entry 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry 0..* Reference(Vital Signs Profile) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
From this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* USRealmHeader A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Consultation Note
Binding: ConsultDocumentType (required)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 1..1 Reference(US Core Encounter Profile) encompassingEncounter
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement attester
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section C 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 0..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:allergies_and_intolerances_section SC 1..1 BackboneElement Allergies and Intolerances Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Allergies and adverse reactions
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:allergy_intolerance_entry SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:history_of_present_illness_section SC 1..1 BackboneElement History of Present Illness Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept History of present illness
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:problem_section C 1..1 BackboneElement Problem Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Problem list
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:problem_section_entry SC 0..* Reference(US Core Condition Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:medications_section C 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medication use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:physical_exam_section C 0..1 BackboneElement Physical Exam Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:results_section C 0..1 BackboneElement Results Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Relevant diagnostic tests/laboratory data
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Laboratory Result Observation Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:advance_directives_section SC 0..1 BackboneElement Advance Directives Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string title
..... code S 1..1 CodeableConcept Advance directives
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:advance_directive_entry SC 0..* Reference(Consent) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:assessment_and_plan_section C 0..1 BackboneElement Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessment (evaluation) and plan
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile | Observation | Communication) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:assessment_section C 0..1 BackboneElement Assessment Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Assessments (evaluation)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:chief_complaint_and_reason_for_visit_section C 0..1 BackboneElement Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint and reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:chief_complaint_section C 0..1 BackboneElement Chief Complaint Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Chief complaint
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:family_history_section C 0..1 BackboneElement Family History Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Family history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(FamilyMemberHistory) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:functional_status_section C 0..1 BackboneElement Functional Status Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Functional status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:general_status_section C 0..1 BackboneElement General Status Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Physical findings of General status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:past_medical_history_section C 0..1 BackboneElement Past Medical History Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Past Medical History
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Condition Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:immunizations_section C 0..1 BackboneElement Immunizations Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of immunization
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:medical_equipment_section C 0..1 BackboneElement Medical Equipment Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of medical device use
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:medical_equipment_entry SC 0..* Reference(Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:mental_status_section C 0..1 BackboneElement Mental Status Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Mental status
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Observation) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:nutrition_section C 0..1 BackboneElement Nutrition Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Diet and nutrition
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(NutritionOrder | ClinicalImpression) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:plan_of_treatment_section C 0..1 BackboneElement Plan of Treatment Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Plan of treatment
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:procedures_section C 0..1 BackboneElement Procedures Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept History of Procedures
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:reason_for_visit_section C 0..1 BackboneElement Reason for Visit Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Reason for visit
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:review_of_systems_section C 0..1 BackboneElement Review of Systems Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Review of systems
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative This section contains only human readable content
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:social_history_section C 0..1 BackboneElement Social History Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Social history
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(US Core Smoking Status Observation Profile) Smoking status
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:vital_signs_section C 0..1 BackboneElement Vital Signs Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string title
..... code 1..1 CodeableConcept Vital signs
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... Slices for entry C 0..* Reference(Resource) entry
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEntry C 0..* Reference(Vital Signs Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typerequiredConsultDocumentType
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31
From this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
From the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.codeexamplePattern Value: LOINC Code 48765-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:allergies_and_intolerances_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:history_of_present_illness_section.codeexamplePattern Value: LOINC Code 10164-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:history_of_present_illness_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:history_of_present_illness_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:history_of_present_illness_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:problem_section.codeexamplePattern Value: LOINC Code 11450-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:problem_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:problem_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:problem_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:medications_section.codeexamplePattern Value: LOINC Code 10160-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medications_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:medications_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:medications_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:physical_exam_section.codeexamplePattern Value: LOINC Code 29545-1
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:physical_exam_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:physical_exam_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:physical_exam_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:results_section.codeexamplePattern Value: LOINC Code 30954-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:results_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:results_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:results_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:advance_directives_section.codeexamplePattern Value: LOINC Code 42348-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:advance_directives_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:advance_directives_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:advance_directives_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:assessment_and_plan_section.codeexamplePattern Value: LOINC Code 51847-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_and_plan_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:assessment_and_plan_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:assessment_and_plan_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:assessment_section.codeexamplePattern Value: LOINC Code 51848-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:assessment_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:assessment_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:assessment_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.codeexamplePattern Value: LOINC Code 46239-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:chief_complaint_section.codeexamplePattern Value: LOINC Code 10154-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:chief_complaint_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:chief_complaint_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:chief_complaint_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:family_history_section.codeexamplePattern Value: LOINC Code 10157-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:family_history_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:family_history_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:family_history_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:functional_status_section.codeexamplePattern Value: LOINC Code 47420-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:functional_status_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:functional_status_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:functional_status_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:general_status_section.codeexamplePattern Value: LOINC Code 10210-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:general_status_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:general_status_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:general_status_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:past_medical_history_section.codeexamplePattern Value: LOINC Code 11348-0
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:past_medical_history_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:past_medical_history_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:past_medical_history_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:immunizations_section.codeexamplePattern Value: LOINC Code 11369-6
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:immunizations_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:immunizations_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:immunizations_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:medical_equipment_section.codeexamplePattern Value: LOINC Code 46264-8
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:medical_equipment_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:medical_equipment_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:medical_equipment_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:mental_status_section.codeexamplePattern Value: LOINC Code 10190-7
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:mental_status_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:mental_status_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:mental_status_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:nutrition_section.codeexamplePattern Value: LOINC Code 61144-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:nutrition_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:nutrition_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:nutrition_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:plan_of_treatment_section.codeexamplePattern Value: LOINC Code 18776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:plan_of_treatment_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:plan_of_treatment_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:plan_of_treatment_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:procedures_section.codeexamplePattern Value: LOINC Code 47519-4
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:procedures_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:procedures_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:procedures_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:reason_for_visit_section.codeexamplePattern Value: LOINC Code 29299-5
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:reason_for_visit_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:reason_for_visit_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:reason_for_visit_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:review_of_systems_section.codeexamplePattern Value: LOINC Code 10187-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:review_of_systems_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:review_of_systems_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:review_of_systems_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:social_history_section.codeexamplePattern Value: LOINC Code 29762-2
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:social_history_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:social_history_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:social_history_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard
Composition.section:vital_signs_section.codeexamplePattern Value: LOINC Code 8716-3
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section:vital_signs_section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:vital_signs_section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section:vital_signs_section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

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