C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot
C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot
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/Referral-Note | Version: 2.0.0-ballot | |||
| Active as of 2024-12-17 | Computable Name: ReferralNote | |||
A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.
Examples of referral situations are:
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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  type |
S | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required) |
  Slices for section |
0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
   section:allergies_and_intolerances_section |
S | 1..1 | BackboneElement | Allergies and Intolerances Section |
  title |
S | 1..1 | string | title |
 code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text |
S | 1..1 | Narrative | text |
 Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
 entry:allergies_and_intolerances_entry |
S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:medications_section |
S | 1..1 | BackboneElement | Medications Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:medications_entry |
S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| section:problem_section |
S | 1..1 | BackboneElement | Problem Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Problem list Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:problem_entry |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:reason_for_referral_section |
S | 1..1 | BackboneElement | Reason for Referral Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |
| text |
S | 1..1 | Narrative | This section contains only human readable content |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:reason_for_referral_entry |
S | 0..* | Reference(ServiceRequest) | A reference to data that supports this section |
| section:functional_status_section |
S | 0..1 | BackboneElement | Functional Status Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:functional_status_entry |
S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:mental_status_section |
S | 0..1 | BackboneElement | Mental Status Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10190-7 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:mental_status_entry |
S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:nutrition_section |
S | 0..1 | BackboneElement | Nutrition Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Diet and nutrition Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:nutrition_entry |
S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:plan_of_treatment_section |
S | 0..1 | BackboneElement | Plan of Treatment Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Plan of treatment Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:sliceEntry |
0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
| section:results_section |
S | 0..1 | BackboneElement | Results Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:results_entry |
S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| section:assessment_and_plan_section |
S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Assessment and plan Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| text |
1..1 | Narrative | text | |
| Slices for entry |
0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:assessment_and_plan_entry |
S | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:advance_directives_section |
S | 0..1 | BackboneElement | Advance Directives Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Advance directives Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:advance_directive_entry |
S | 0..* | Reference(Consent) | A reference to data that supports this section |
| section:assessment_section |
S | 0..1 | BackboneElement | Assessment Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
 text |
S | 1..1 | Narrative | This section contains only human readable content |
| section:family_history_section |
S | 0..1 | BackboneElement | Family History Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | History of family member diseases Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:family_history_entry |
S | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:general_status_section |
S | 0..1 | BackboneElement | General Status Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |
| text |
S | 1..1 | Narrative | This section contains only human readable content |
| section:past_medical_history_section |
S | 0..1 | BackboneElement | Past Medical History Section |
| title |
1..1 | string | title | |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:past_medical_history_entry |
S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:history_of_present_illness_section |
S | 0..1 | BackboneElement | History of Present Illness Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
| text |
S | 1..1 | Narrative | This section contains only human readable content |
| section:immunizations_section |
S | 0..1 | BackboneElement | Immunizations Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | History of immunization Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:immunizations_entry |
S | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section |
| section:medical_equipment_section |
S | 0..1 | BackboneElement | Medical Equipment Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Medical equipment Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:medical_equipment_entry |
S | 0..* | Reference(Device | US Core Procedure Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:physical_exam_section |
S | 0..1 | BackboneElement | Physical Exam Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:physical_exam_entry |
S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:procedures_section |
S | 0..1 | BackboneElement | Procedures Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | History of procedures Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:procedures_entry |
S | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section |
| section:review_of_systems_section |
S | 0..1 | BackboneElement | Review of Systems Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| text |
S | 1..1 | Narrative | This section contains only human readable content |
| section:social_history_section |
S | 0..1 | BackboneElement | Social History Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Social history Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:social_history_entry |
S | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status |
| section:vital_signs_section |
S | 0..1 | BackboneElement | Vital Signs Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Vital signs Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:vital_signs_entry |
S | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:goals_section |
S | 0..1 | BackboneElement | Goals Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Goals Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 61146-7 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:goals_entry |
S | 0..* | Reference(US Core Goal Profile) | entry |
 section:health_concerns_section |
S | 0..1 | BackboneElement | Health Concerns Section |
| title |
S | 1..1 | string | title |
| code |
S | 1..1 | CodeableConcept | Health concerns section code Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |
| text |
S | 1..1 | Narrative | text |
| Slices for entry |
0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:health_concerns_entry |
S | 0..* | Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.type | required | ReferralDocumentTypehttp://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3from this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |||||
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children | ||||
| language |
S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
ele-1: All FHIR elements must have a @value or children | ||||
 Slices for extension |
Content/Rules for all slices | |||||||
  versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| version_number_extension |
S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| data_enterer_extension |
S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| informant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| information_recipient_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| performer_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| authorization_extension |
S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| order_extension |
S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
 identifier |
SΣ | 1..1 | Identifier | identifier ele-1: All FHIR elements must have a @value or children | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children | ||||
| type |
SΣ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required) ele-1: All FHIR elements must have a @value or children | ||||
 subject |
SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children | ||||
| encounter |
SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition ele-1: All FHIR elements must have a @value or children | ||||
| date |
SΣ | 1..1 | dateTime | date ele-1: All FHIR elements must have a @value or children | ||||
| author |
SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children | ||||
| title |
SΣ | 1..1 | string | Document Title ele-1: All FHIR elements must have a @value or children | ||||
| Slices for attester |
0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode ele-1: All FHIR elements must have a @value or children | |||||
| attester:All Slices |
Content/Rules for all slices | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | |||||
| attester:legal_attester |
S | 0..1 | BackboneElement | attester ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: legal | ||||
| party |
S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party ele-1: All FHIR elements must have a @value or children | ||||
| attester:professional_attester |
S | 0..* | BackboneElement | attester ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: professional | ||||
| party |
S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party ele-1: All FHIR elements must have a @value or children | ||||
| attester:personal_attester |
S | 0..* | BackboneElement | attester ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Fixed Value: personal | ||||
| party |
S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party ele-1: All FHIR elements must have a @value or children | ||||
| custodian |
SΣ | 1..1 | Reference(US Core Organization Profile) | custodian ele-1: All FHIR elements must have a @value or children | ||||
| Slices for section |
C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| section:All Slices |
Content/Rules for all slices | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| section:allergies_and_intolerances_section |
SC | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:allergies_and_intolerances_entry |
SC | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:medications_section |
SC | 1..1 | BackboneElement | Medications Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:medications_entry |
SC | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:problem_section |
SC | 1..1 | BackboneElement | Problem Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:problem_entry |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:reason_for_referral_section |
SC | 1..1 | BackboneElement | Reason for Referral Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |||||
| text |
SC | 1..1 | Narrative | This section contains only human readable content ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:reason_for_referral_entry |
SC | 0..* | Reference(ServiceRequest) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:functional_status_section |
SC | 0..1 | BackboneElement | Functional Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:functional_status_entry |
SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:mental_status_section |
SC | 0..1 | BackboneElement | Mental Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10190-7 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:mental_status_entry |
SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:nutrition_section |
SC | 0..1 | BackboneElement | Nutrition Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:nutrition_entry |
SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:plan_of_treatment_section |
SC | 0..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:sliceEntry |
C | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:results_section |
SC | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:results_entry |
SC | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:assessment_and_plan_section |
SC | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Assessment and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |||||
| text |
C | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:assessment_and_plan_entry |
SC | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:advance_directives_section |
SC | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:advance_directive_entry |
SC | 0..* | Reference(Consent) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:assessment_section |
SC | 0..1 | BackboneElement | Assessment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |||||
| text |
SC | 1..1 | Narrative | This section contains only human readable content ele-1: All FHIR elements must have a @value or children | ||||
| section:family_history_section |
SC | 0..1 | BackboneElement | Family History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | History of family member diseases Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:family_history_entry |
SC | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:general_status_section |
SC | 0..1 | BackboneElement | General Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |||||
| text |
SC | 1..1 | Narrative | This section contains only human readable content ele-1: All FHIR elements must have a @value or children | ||||
| section:past_medical_history_section |
SC | 0..1 | BackboneElement | Past Medical History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
1..1 | string | title ele-1: All FHIR elements must have a @value or children | |||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:past_medical_history_entry |
SC | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:history_of_present_illness_section |
SC | 0..1 | BackboneElement | History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |||||
| text |
SC | 1..1 | Narrative | This section contains only human readable content ele-1: All FHIR elements must have a @value or children | ||||
| section:immunizations_section |
SC | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:immunizations_entry |
SC | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:medical_equipment_section |
SC | 0..1 | BackboneElement | Medical Equipment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | Medical equipment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:medical_equipment_entry |
SC | 0..* | Reference(Device | US Core Procedure Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:physical_exam_section |
SC | 0..1 | BackboneElement | Physical Exam Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:physical_exam_entry |
SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ele-1: All FHIR elements must have a @value or children | ||||
| section:procedures_section |
SC | 0..1 | BackboneElement | Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | History of procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| text |
SC | 1..1 | Narrative | text ele-1: All FHIR elements must have a @value or children | ||||
| Slices for entry |
C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children | ||||
| entry:procedures_entry |
SC | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children | ||||
| section:review_of_systems_section |
SC | 0..1 | BackboneElement | Review of Systems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | title ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | ||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
| |