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
Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note | Version: 2.0.0-ballot | |||
Standards status: Trial-use | Computable Name: OperativeNote |
The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.
The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
2025 Ballot of C-CDA ↔ FHIR US Core MappingThe 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
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
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0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
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Content/Rules for all slices | |||||||
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0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
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S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
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S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
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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 | ||||
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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 | ||||
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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 | ||||
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S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
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S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
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S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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SΣ | 1..1 | Identifier | identifier | ||||
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?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
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SΣ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required) | ||||
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SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
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SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
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SΣ | 1..1 | dateTime | date | ||||
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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 | ||||
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SΣ | 1..1 | string | Document Title | ||||
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0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
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Content/Rules for all slices | |||||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
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S | 0..1 | BackboneElement | attester | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
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S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
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S | 0..* | BackboneElement | attester | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
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S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
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S | 0..* | BackboneElement | attester | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
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S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
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SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
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C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||
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Content/Rules for all slices | |||||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SC | 1..1 | BackboneElement | Anesthesia Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Anesthesia Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Complications Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Complications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Preoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Preoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10219-4 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Procedure Estimated Blood Loss Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Estimated Blood Loss Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59770-8 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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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 | ||||
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SC | 1..1 | BackboneElement | Procedure Findings Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Procedure Specimens Taken Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Specimens Taken Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59773-2 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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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 | ||||
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SC | 1..1 | BackboneElement | Postoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Postoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10218-6 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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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 | ||||
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SC | 1..1 | BackboneElement | Procedure Description Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | string | title | |||||
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S | 1..1 | CodeableConcept | Procedure Description Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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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 | ||||
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SC | 0..1 | BackboneElement | Operative Note Surgical Procedure Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Operative Note Surgical Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10223-6 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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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 | ||||
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SC | 0..1 | BackboneElement | Operative Note Fluids Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
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0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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SC | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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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. | ||||
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SC | 0..1 | BackboneElement | Planned Procedure Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Planned Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59772-4 | |||||
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0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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SC | 0..1 | BackboneElement | Procedure Disposition Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Disposition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59775-7 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
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SC | 0..1 | BackboneElement | Procedure Indications Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Indications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 0..1 | BackboneElement | Procedure Implants Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Implants Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59771-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Surgical Drains Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard | ||||
Composition.type | required | SurgicalOperationNoteDocumentTypeCodehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 From this IG | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:complications_section.code | example | Pattern Value: LOINC Code 55109-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required) |
![]() ![]() ![]() |
0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Anesthesia Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Anesthesia Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Complications Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Complications Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Preoperative Diagnosis Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Preoperative Diagnosis Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10219-4 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Procedure Estimated Blood Loss Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Estimated Blood Loss Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59770-8 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 1..1 | BackboneElement | Procedure Findings Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Procedure Findings Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5 | |
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S | 1..1 | Narrative | text |
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0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
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S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
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S | 1..1 | BackboneElement | Procedure Specimens Taken Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Procedure Specimens Taken Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59773-2 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 1..1 | BackboneElement | Postoperative Diagnosis Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Postoperative Diagnosis Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10218-6 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 1..1 | BackboneElement | Procedure Description Section |
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1..1 | string | title | |
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S | 1..1 | CodeableConcept | Procedure Description Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 0..1 | BackboneElement | Operative Note Surgical Procedure Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Operative Note Surgical Procedure Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10223-6 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 0..1 | BackboneElement | Operative Note Fluids Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Operative Note Fluids Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 0..1 | BackboneElement | Plan of Treatment Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
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S | 1..1 | Narrative | text |
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S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() |
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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. | |
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S | 0..1 | BackboneElement | Planned Procedure Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Planned Procedure Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59772-4 | |
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S | 1..1 | Narrative | text |
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0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
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S | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
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S | 0..1 | BackboneElement | Procedure Disposition Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Procedure Disposition Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59775-7 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 0..1 | BackboneElement | Procedure Indications Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Procedure Indications Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
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S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
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S | 0..1 | BackboneElement | Procedure Implants Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Procedure Implants Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59771-6 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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S | 0..1 | BackboneElement | Surgical Drains Section |
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S | 1..1 | string | title |
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S | 1..1 | CodeableConcept | Surgical Drains Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8 | |
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S | 1..1 | Narrative | This section contains only human readable content |
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Path | Conformance | ValueSet | URI |
Composition.type | required | SurgicalOperationNoteDocumentTypeCodehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 From this IG |
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
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0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
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S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
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S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
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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 | ||||
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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 | ||||
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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 | ||||
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S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
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S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
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S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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SΣ | 1..1 | Identifier | identifier | ||||
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?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
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SΣ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required) | ||||
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Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
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SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
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SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
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SΣ | 1..1 | dateTime | date | ||||
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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 | ||||
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SΣ | 1..1 | string | Document Title | ||||
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0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
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0..1 | dateTime | When the composition was attested | |||||
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0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
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S | 0..1 | BackboneElement | attester | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
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0..1 | dateTime | When the composition was attested | |||||
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S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
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S | 0..* | BackboneElement | attester | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
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0..1 | dateTime | When the composition was attested | |||||
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S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
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S | 0..* | BackboneElement | attester | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
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0..1 | dateTime | When the composition was attested | |||||
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S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
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SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
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0..* | BackboneElement | Relationships to other compositions/documents | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
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1..1 | Target of the relationship | ||||||
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Identifier | |||||||
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Reference(Composition) | |||||||
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Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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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. | ||||
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Σ | 0..1 | Period | The period covered by the documentation | ||||
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Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
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C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Label for section (e.g. for ToC) | |||||
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0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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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 | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 1..1 | BackboneElement | Anesthesia Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Anesthesia Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 1..1 | BackboneElement | Complications Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Complications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Preoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Preoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10219-4 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Estimated Blood Loss Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Estimated Blood Loss Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59770-8 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Findings Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Specimens Taken Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Specimens Taken Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59773-2 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Postoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Postoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10218-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Description Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | string | title | |||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Description Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Operative Note Surgical Procedure Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Surgical Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10223-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Operative Note Fluids Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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SC | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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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. | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Planned Procedure Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Planned Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59772-4 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Procedure Disposition Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Disposition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59775-7 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Procedure Indications Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Indications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Procedure Implants Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Implants Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59771-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Surgical Drains Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard | ||||
Composition.type | required | SurgicalOperationNoteDocumentTypeCodehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 From this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:anesthesia_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:anesthesia_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:anesthesia_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:complications_section.code | example | Pattern Value: LOINC Code 55109-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:complications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:complications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:complications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_findings_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_findings_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_findings_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_description_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_description_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_description_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:planned_procedure_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:planned_procedure_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:planned_procedure_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_indications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_indications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_indications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_implants_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_implants_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_implants_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:surgical_drains_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:surgical_drains_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:surgical_drains_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Summary
Mandatory: 32 elements(24 nested mandatory elements)
Must-Support: 71 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
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0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
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Content/Rules for all slices | |||||||
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0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
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S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
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S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
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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 | ||||
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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 | ||||
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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 | ||||
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S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
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S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
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S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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SΣ | 1..1 | Identifier | identifier | ||||
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?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
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SΣ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required) | ||||
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SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
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SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
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SΣ | 1..1 | dateTime | date | ||||
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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 | ||||
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SΣ | 1..1 | string | Document Title | ||||
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0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
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Content/Rules for all slices | |||||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
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S | 0..1 | BackboneElement | attester | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
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S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
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S | 0..* | BackboneElement | attester | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
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S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
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S | 0..* | BackboneElement | attester | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
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S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
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SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
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C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||
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Content/Rules for all slices | |||||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SC | 1..1 | BackboneElement | Anesthesia Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Anesthesia Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Complications Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Complications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Preoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Preoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 10219-4 | |||||
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0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
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SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Procedure Estimated Blood Loss Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Estimated Blood Loss Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59770-8 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Findings Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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SC | 1..1 | BackboneElement | Procedure Specimens Taken Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Specimens Taken Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59773-2 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
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SC | 1..1 | BackboneElement | Postoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Postoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10218-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Description Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | string | title | |||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Description Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |||||
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0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Operative Note Surgical Procedure Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Surgical Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10223-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Operative Note Fluids Section Constraints: cmp-1, cmp-2 | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
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. | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Planned Procedure Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Planned Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59772-4 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Procedure Disposition Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Disposition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59775-7 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Procedure Indications Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Indications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Procedure Implants Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Implants Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59771-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Surgical Drains Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard | ||||
Composition.type | required | SurgicalOperationNoteDocumentTypeCodehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 From this IG | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:complications_section.code | example | Pattern Value: LOINC Code 55109-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required) |
![]() ![]() ![]() |
0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Anesthesia Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Anesthesia Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section |
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S | 1..1 | BackboneElement | Complications Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Complications Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Preoperative Diagnosis Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Preoperative Diagnosis Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10219-4 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Procedure Estimated Blood Loss Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Estimated Blood Loss Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59770-8 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Procedure Findings Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Findings Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Procedure Specimens Taken Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Specimens Taken Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59773-2 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Postoperative Diagnosis Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Postoperative Diagnosis Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10218-6 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 1..1 | BackboneElement | Procedure Description Section |
![]() ![]() ![]() ![]() ![]() |
1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Description Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |
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S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Operative Note Surgical Procedure Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Surgical Procedure Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10223-6 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Operative Note Fluids Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Fluids Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Plan of Treatment Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() |
![]() ![]() ![]() ![]() ![]() ![]() |
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. | |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Planned Procedure Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Planned Procedure Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59772-4 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Procedure Disposition Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Disposition Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59775-7 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Procedure Indications Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Indications Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Procedure Implants Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Implants Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59771-6 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Surgical Drains Section |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Surgical Drains Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8 | |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Narrative | This section contains only human readable content |
![]() |
Path | Conformance | ValueSet | URI |
Composition.type | required | SurgicalOperationNoteDocumentTypeCodehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 From this IG |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
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S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
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S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
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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 | ||||
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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 | ||||
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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 | ||||
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S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
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S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
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S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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SΣ | 1..1 | Identifier | identifier | ||||
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?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
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SΣ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required) | ||||
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Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
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SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
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SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
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SΣ | 1..1 | dateTime | date | ||||
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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 | ||||
![]() ![]() ![]() |
SΣ | 1..1 | string | Document Title | ||||
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0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
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Content/Rules for all slices | |||||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | dateTime | When the composition was attested | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
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S | 0..1 | BackboneElement | attester | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | dateTime | When the composition was attested | |||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
![]() ![]() ![]() ![]() |
S | 0..* | BackboneElement | attester | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | dateTime | When the composition was attested | |||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
![]() ![]() ![]() ![]() |
S | 0..* | BackboneElement | attester | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | dateTime | When the composition was attested | |||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
![]() ![]() ![]() |
SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
![]() ![]() ![]() |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
![]() ![]() ![]() ![]() |
1..1 | Target of the relationship | ||||||
![]() ![]() ![]() ![]() ![]() |
Identifier | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Composition) | |||||||
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Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
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. | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Period | The period covered by the documentation | ||||
![]() ![]() ![]() ![]() |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
![]() ![]() ![]() |
C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() |
Content/Rules for all slices | |||||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Label for section (e.g. for ToC) | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Anesthesia Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Anesthesia Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Complications Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Complications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Preoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Preoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10219-4 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Estimated Blood Loss Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Estimated Blood Loss Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59770-8 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Findings Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Specimens Taken Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Specimens Taken Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59773-2 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Postoperative Diagnosis Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Postoperative Diagnosis Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10218-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Procedure Description Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | string | title | |||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Description Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Operative Note Surgical Procedure Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Surgical Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10223-6 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Operative Note Fluids Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
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. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Planned Procedure Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Planned Procedure Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59772-4 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
SC | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SC | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Procedure Disposition Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Disposition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 59775-7 | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
![]() ![]() ![]() ![]() ![]() |
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 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() ![]() ![]() ![]() |
SC | 0..1 | BackboneElement | Procedure Indications Section Constraints: cmp-1, cmp-2 | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | title | ||||
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Procedure Indications Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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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 | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
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SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Procedure Implants Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Procedure Implants Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 59771-6 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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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 | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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SC | 0..1 | BackboneElement | Surgical Drains Section Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | string | title | ||||
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S | 1..1 | CodeableConcept | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8 | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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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 | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard | ||||
Composition.type | required | SurgicalOperationNoteDocumentTypeCodehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 From this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:anesthesia_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:anesthesia_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:anesthesia_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:complications_section.code | example | Pattern Value: LOINC Code 55109-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:complications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:complications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:complications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:preoperative_diagnosis_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_estimated_blood_loss_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_findings_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_findings_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_findings_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_specimens_taken_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:postoperative_diagnosis_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_description_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_description_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_description_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:operative_note_surgical_procedure_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:operative_note_fluids_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:planned_procedure_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:planned_procedure_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:planned_procedure_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_disposition_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_indications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_indications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_indications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:procedure_implants_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:procedure_implants_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:procedure_implants_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard | ||||
Composition.section:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard | ||||
Composition.section:surgical_drains_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard | ||||
Composition.section:surgical_drains_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order From the FHIR Standard | ||||
Composition.section:surgical_drains_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Summary
Mandatory: 32 elements(24 nested mandatory elements)
Must-Support: 71 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron