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

## Resource Profile: Referral Note

Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note | Version: 2.0.0-ballot
Standards status: Trial-use | 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:

- When a patient is referred from a family physician to a cardiologist for cardiac evaluation.
- When patient is sent by a cardiologist to an emergency department for angina.
- When a patient is referred by a nurse practitioner to an audiologist for hearing screening.
- When a patient is referred by a hospitalist to social services.

> 2025 Ballot of C-CDA ↔ FHIR US Core Mapping

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

Usages:

- Examples for this Profile: Composition/Referral-Note-Example
- CapabilityStatements using this Profile: CCDA on FHIR Client and CCDA on FHIR Server

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Slices for extension |  |  |  | Content/Rules for all slices
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required)
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
attester:legal_attester | S | 0..1 | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
section:allergies_and_intolerances_section | S C | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:allergies_and_intolerances_entry | S C | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section
section:medications_section | S C | 1..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medications_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
section:problem_section | S C | 1..1 | BackboneElement | Problem Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:reason_for_referral_section | S C | 1..1 | BackboneElement | Reason for Referral Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:reason_for_referral_entry | S C | 0..* | Reference(ServiceRequest) | A reference to data that supports this section
section:functional_status_section | S C | 0..1 | BackboneElement | Functional Status Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:functional_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:mental_status_section | S C | 0..1 | BackboneElement | Mental Status Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10190-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:mental_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:nutrition_section | S C | 0..1 | BackboneElement | Nutrition Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:nutrition_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:plan_of_treatment_section | S C | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:results_section | S C | 0..1 | BackboneElement | Results Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:results_entry | S C | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section
section:assessment_and_plan_section | S C | 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. Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Assessment and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:assessment_and_plan_entry | S C | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:advance_directives_section | S C | 0..1 | BackboneElement | Advance Directives Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:advance_directive_entry | S C | 0..* | Reference(Consent) | A reference to data that supports this section
section:assessment_section | S C | 0..1 | BackboneElement | Assessment Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:family_history_section | S C | 0..1 | BackboneElement | Family History Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of family member diseases Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:family_history_entry | S C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:general_status_section | S C | 0..1 | BackboneElement | General Status Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:past_medical_history_section | S C | 0..1 | BackboneElement | Past Medical History Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:past_medical_history_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:history_of_present_illness_section | S C | 0..1 | BackboneElement | History of Present Illness Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:immunizations_section | S C | 0..1 | BackboneElement | Immunizations Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:immunizations_entry | S C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section
section:medical_equipment_section | S C | 0..1 | BackboneElement | Medical Equipment Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medical equipment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medical_equipment_entry | S C | 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 C | 0..1 | BackboneElement | Physical Exam Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:physical_exam_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:procedures_section | S C | 0..1 | BackboneElement | Procedures Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:procedures_entry | S C | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section
section:review_of_systems_section | S C | 0..1 | BackboneElement | Review of Systems Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:social_history_section | S C | 0..1 | BackboneElement | Social History Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Social history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:social_history_entry | S C | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status
section:vital_signs_section | S C | 0..1 | BackboneElement | Vital Signs Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:vital_signs_entry | S C | 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 C | 0..1 | BackboneElement | Goals Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Goals Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61146-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:goals_entry | S C | 0..* | Reference(US Core Goal Profile) | entry
section:health_concerns_section | S C | 0..1 | BackboneElement | Health Concerns Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Health concerns section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:health_concerns_entry | S C | 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

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Composition.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Composition.status | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` From the FHIR Standard
Composition.type | required | ReferralDocumentType `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3` From this IG
Composition.attester.mode | required | CompositionAttestationMode `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:legal_attester.mode | required | Fixed Value: legal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:professional_attester.mode | required | Fixed Value: professional `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:personal_attester.mode | required | Fixed Value: personal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.code | example | Pattern Value: LOINC Code 48765-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medications_section.code | example | Pattern Value: LOINC Code 10160-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:problem_section.code | example | Pattern Value: LOINC Code 11450-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:reason_for_referral_section.code | example | Pattern Value: LOINC Code 42349-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:functional_status_section.code | example | Pattern Value: LOINC Code 47420-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:mental_status_section.code | example | Pattern Value: LOINC Code 10190-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:nutrition_section.code | example | Pattern Value: LOINC Code 61144-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:results_section.code | example | Pattern Value: LOINC Code 30954-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_and_plan_section.code | example | Pattern Value: LOINC Code 51847-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:advance_directives_section.code | example | Pattern Value: LOINC Code 42348-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_section.code | example | Pattern Value: LOINC Code 51848-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:family_history_section.code | example | Pattern Value: LOINC Code 10157-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:general_status_section.code | example | Pattern Value: LOINC Code 10210-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:past_medical_history_section.code | example | Pattern Value: LOINC Code 11348-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:history_of_present_illness_section.code | example | Pattern Value: LOINC Code 10164-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:immunizations_section.code | example | Pattern Value: LOINC Code 11369-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medical_equipment_section.code | example | Pattern Value: LOINC Code 46264-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:physical_exam_section.code | example | Pattern Value: LOINC Code 29545-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedures_section.code | example | Pattern Value: LOINC Code 47519-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:review_of_systems_section.code | example | Pattern Value: LOINC Code 10187-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:social_history_section.code | example | Pattern Value: LOINC Code 29762-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:vital_signs_section.code | example | Pattern Value: LOINC Code 8716-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:goals_section.code | example | Pattern Value: LOINC Code 61146-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:health_concerns_section.code | example | Pattern Value: LOINC Code 75310-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Composition.type | required | ReferralDocumentType `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3` From this IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required)
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
relatesTo |  | 0..* | BackboneElement | Relationships to other compositions/documents
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x] |  | 1..1 |  | Target of the relationship
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period | Σ | 0..1 | Period | The period covered by the documentation
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 0..1 | string | Label for section (e.g. for ToC)
code |  | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:allergies_and_intolerances_section | S C | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:allergies_and_intolerances_entry | S C | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:medications_section | S C | 1..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medications_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:problem_section | S C | 1..1 | BackboneElement | Problem Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:reason_for_referral_section | S C | 1..1 | BackboneElement | Reason for Referral Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:reason_for_referral_entry | S C | 0..* | Reference(ServiceRequest) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:functional_status_section | S C | 0..1 | BackboneElement | Functional Status Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:functional_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:mental_status_section | S C | 0..1 | BackboneElement | Mental Status Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10190-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:mental_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:nutrition_section | S C | 0..1 | BackboneElement | Nutrition Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:nutrition_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:plan_of_treatment_section | S C | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:results_section | S C | 0..1 | BackboneElement | Results Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:results_entry | S C | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:assessment_and_plan_section | S C | 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. Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Assessment and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:assessment_and_plan_entry | S C | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:advance_directives_section | S C | 0..1 | BackboneElement | Advance Directives Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:advance_directive_entry | S C | 0..* | Reference(Consent) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:assessment_section | S C | 0..1 | BackboneElement | Assessment Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:family_history_section | S C | 0..1 | BackboneElement | Family History Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of family member diseases Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:family_history_entry | S C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:general_status_section | S C | 0..1 | BackboneElement | General Status Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:past_medical_history_section | S C | 0..1 | BackboneElement | Past Medical History Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:past_medical_history_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:history_of_present_illness_section | S C | 0..1 | BackboneElement | History of Present Illness Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:immunizations_section | S C | 0..1 | BackboneElement | Immunizations Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:immunizations_entry | S C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:medical_equipment_section | S C | 0..1 | BackboneElement | Medical Equipment Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medical equipment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medical_equipment_entry | S C | 0..* | Reference(Device | US Core Procedure Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:physical_exam_section | S C | 0..1 | BackboneElement | Physical Exam Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:physical_exam_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:procedures_section | S C | 0..1 | BackboneElement | Procedures Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:procedures_entry | S C | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:review_of_systems_section | S C | 0..1 | BackboneElement | Review of Systems Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:social_history_section | S C | 0..1 | BackboneElement | Social History Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Social history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:social_history_entry | S C | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:vital_signs_section | S C | 0..1 | BackboneElement | Vital Signs Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:vital_signs_entry | S C | 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.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:goals_section | S C | 0..1 | BackboneElement | Goals Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Goals Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61146-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:goals_entry | S C | 0..* | Reference(US Core Goal Profile) | entry
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:health_concerns_section | S C | 0..1 | BackboneElement | Health Concerns Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Health concerns section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:health_concerns_entry | S C | 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.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Composition.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Composition.status | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` From the FHIR Standard
Composition.type | required | ReferralDocumentType `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3` From this IG
Composition.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` From the FHIR Standard
Composition.attester.mode | required | CompositionAttestationMode `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:legal_attester.mode | required | Fixed Value: legal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:professional_attester.mode | required | Fixed Value: professional `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:personal_attester.mode | required | Fixed Value: personal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` From the FHIR Standard
Composition.event.code | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode`
Composition.section.code | example | DocumentSectionCodes `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.code | example | Pattern Value: LOINC Code 48765-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:medications_section.code | example | Pattern Value: LOINC Code 10160-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medications_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medications_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medications_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:problem_section.code | example | Pattern Value: LOINC Code 11450-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:problem_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:problem_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:problem_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:reason_for_referral_section.code | example | Pattern Value: LOINC Code 42349-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:reason_for_referral_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:reason_for_referral_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:reason_for_referral_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:functional_status_section.code | example | Pattern Value: LOINC Code 47420-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:functional_status_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:functional_status_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:functional_status_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:mental_status_section.code | example | Pattern Value: LOINC Code 10190-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:mental_status_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:mental_status_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:mental_status_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:nutrition_section.code | example | Pattern Value: LOINC Code 61144-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:nutrition_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:nutrition_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:nutrition_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:plan_of_treatment_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:results_section.code | example | Pattern Value: LOINC Code 30954-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:results_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:results_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:results_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:assessment_and_plan_section.code | example | Pattern Value: LOINC Code 51847-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_and_plan_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:advance_directives_section.code | example | Pattern Value: LOINC Code 42348-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:advance_directives_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:advance_directives_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:advance_directives_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:assessment_section.code | example | Pattern Value: LOINC Code 51848-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:assessment_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:family_history_section.code | example | Pattern Value: LOINC Code 10157-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:family_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:family_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:family_history_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:general_status_section.code | example | Pattern Value: LOINC Code 10210-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:general_status_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:general_status_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:general_status_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:past_medical_history_section.code | example | Pattern Value: LOINC Code 11348-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:past_medical_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:past_medical_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:past_medical_history_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:history_of_present_illness_section.code | example | Pattern Value: LOINC Code 10164-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:history_of_present_illness_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:history_of_present_illness_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:history_of_present_illness_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:immunizations_section.code | example | Pattern Value: LOINC Code 11369-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:immunizations_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:immunizations_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:immunizations_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:medical_equipment_section.code | example | Pattern Value: LOINC Code 46264-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medical_equipment_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medical_equipment_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medical_equipment_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:physical_exam_section.code | example | Pattern Value: LOINC Code 29545-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:physical_exam_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedures_section.code | example | Pattern Value: LOINC Code 47519-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedures_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedures_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedures_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:review_of_systems_section.code | example | Pattern Value: LOINC Code 10187-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:review_of_systems_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:social_history_section.code | example | Pattern Value: LOINC Code 29762-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:social_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:social_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:social_history_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:vital_signs_section.code | example | Pattern Value: LOINC Code 8716-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:vital_signs_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:goals_section.code | example | Pattern Value: LOINC Code 61146-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:goals_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:goals_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:goals_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:health_concerns_section.code | example | Pattern Value: LOINC Code 75310-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:health_concerns_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:health_concerns_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:health_concerns_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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: 16 elements(63 nested mandatory elements)
Must-Support: 119 elements

Structures

This structure refers to these other structures:

- US Core AllergyIntolerance Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance)
- US Core Medication Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication)
- US Core MedicationRequest Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest)
- US Core Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
- US Core Goal Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal)
- US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)
- US Core Laboratory Result Observation Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab)
- US Core Immunization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization)
- US Core Procedure Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure)
- US Core Smoking Status Observation Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus)
- Vital Signs Profile (http://hl7.org/fhir/StructureDefinition/vitalsigns)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Composition.section
- The element 1 is sliced based on the value of Composition.section.entry

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Slices for extension |  |  |  | Content/Rules for all slices
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required)
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
attester:legal_attester | S | 0..1 | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
section:allergies_and_intolerances_section | S C | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:allergies_and_intolerances_entry | S C | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section
section:medications_section | S C | 1..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medications_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
section:problem_section | S C | 1..1 | BackboneElement | Problem Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:reason_for_referral_section | S C | 1..1 | BackboneElement | Reason for Referral Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:reason_for_referral_entry | S C | 0..* | Reference(ServiceRequest) | A reference to data that supports this section
section:functional_status_section | S C | 0..1 | BackboneElement | Functional Status Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:functional_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:mental_status_section | S C | 0..1 | BackboneElement | Mental Status Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10190-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:mental_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:nutrition_section | S C | 0..1 | BackboneElement | Nutrition Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:nutrition_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:plan_of_treatment_section | S C | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:results_section | S C | 0..1 | BackboneElement | Results Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:results_entry | S C | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section
section:assessment_and_plan_section | S C | 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. Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Assessment and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:assessment_and_plan_entry | S C | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:advance_directives_section | S C | 0..1 | BackboneElement | Advance Directives Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:advance_directive_entry | S C | 0..* | Reference(Consent) | A reference to data that supports this section
section:assessment_section | S C | 0..1 | BackboneElement | Assessment Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:family_history_section | S C | 0..1 | BackboneElement | Family History Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of family member diseases Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:family_history_entry | S C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:general_status_section | S C | 0..1 | BackboneElement | General Status Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:past_medical_history_section | S C | 0..1 | BackboneElement | Past Medical History Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:past_medical_history_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:history_of_present_illness_section | S C | 0..1 | BackboneElement | History of Present Illness Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:immunizations_section | S C | 0..1 | BackboneElement | Immunizations Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:immunizations_entry | S C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section
section:medical_equipment_section | S C | 0..1 | BackboneElement | Medical Equipment Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medical equipment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medical_equipment_entry | S C | 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 C | 0..1 | BackboneElement | Physical Exam Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:physical_exam_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section:procedures_section | S C | 0..1 | BackboneElement | Procedures Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:procedures_entry | S C | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section
section:review_of_systems_section | S C | 0..1 | BackboneElement | Review of Systems Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:social_history_section | S C | 0..1 | BackboneElement | Social History Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Social history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:social_history_entry | S C | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status
section:vital_signs_section | S C | 0..1 | BackboneElement | Vital Signs Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:vital_signs_entry | S C | 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 C | 0..1 | BackboneElement | Goals Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Goals Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61146-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:goals_entry | S C | 0..* | Reference(US Core Goal Profile) | entry
section:health_concerns_section | S C | 0..1 | BackboneElement | Health Concerns Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Health concerns section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:health_concerns_entry | S C | 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

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Composition.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Composition.status | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` From the FHIR Standard
Composition.type | required | ReferralDocumentType `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3` From this IG
Composition.attester.mode | required | CompositionAttestationMode `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:legal_attester.mode | required | Fixed Value: legal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:professional_attester.mode | required | Fixed Value: professional `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:personal_attester.mode | required | Fixed Value: personal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.code | example | Pattern Value: LOINC Code 48765-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medications_section.code | example | Pattern Value: LOINC Code 10160-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:problem_section.code | example | Pattern Value: LOINC Code 11450-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:reason_for_referral_section.code | example | Pattern Value: LOINC Code 42349-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:functional_status_section.code | example | Pattern Value: LOINC Code 47420-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:mental_status_section.code | example | Pattern Value: LOINC Code 10190-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:nutrition_section.code | example | Pattern Value: LOINC Code 61144-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:results_section.code | example | Pattern Value: LOINC Code 30954-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_and_plan_section.code | example | Pattern Value: LOINC Code 51847-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:advance_directives_section.code | example | Pattern Value: LOINC Code 42348-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_section.code | example | Pattern Value: LOINC Code 51848-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:family_history_section.code | example | Pattern Value: LOINC Code 10157-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:general_status_section.code | example | Pattern Value: LOINC Code 10210-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:past_medical_history_section.code | example | Pattern Value: LOINC Code 11348-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:history_of_present_illness_section.code | example | Pattern Value: LOINC Code 10164-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:immunizations_section.code | example | Pattern Value: LOINC Code 11369-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medical_equipment_section.code | example | Pattern Value: LOINC Code 46264-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:physical_exam_section.code | example | Pattern Value: LOINC Code 29545-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedures_section.code | example | Pattern Value: LOINC Code 47519-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:review_of_systems_section.code | example | Pattern Value: LOINC Code 10187-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:social_history_section.code | example | Pattern Value: LOINC Code 29762-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:vital_signs_section.code | example | Pattern Value: LOINC Code 8716-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:goals_section.code | example | Pattern Value: LOINC Code 61146-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:health_concerns_section.code | example | Pattern Value: LOINC Code 75310-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Composition.type | required | ReferralDocumentType `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3` From this IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required)
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
relatesTo |  | 0..* | BackboneElement | Relationships to other compositions/documents
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x] |  | 1..1 |  | Target of the relationship
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period | Σ | 0..1 | Period | The period covered by the documentation
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 0..1 | string | Label for section (e.g. for ToC)
code |  | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:allergies_and_intolerances_section | S C | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:allergies_and_intolerances_entry | S C | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:medications_section | S C | 1..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medications_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:problem_section | S C | 1..1 | BackboneElement | Problem Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:reason_for_referral_section | S C | 1..1 | BackboneElement | Reason for Referral Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:reason_for_referral_entry | S C | 0..* | Reference(ServiceRequest) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:functional_status_section | S C | 0..1 | BackboneElement | Functional Status Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:functional_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:mental_status_section | S C | 0..1 | BackboneElement | Mental Status Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10190-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:mental_status_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:nutrition_section | S C | 0..1 | BackboneElement | Nutrition Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:nutrition_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:plan_of_treatment_section | S C | 0..1 | BackboneElement | Plan of Treatment Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:results_section | S C | 0..1 | BackboneElement | Results Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:results_entry | S C | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:assessment_and_plan_section | S C | 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. Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Assessment and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:assessment_and_plan_entry | S C | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:advance_directives_section | S C | 0..1 | BackboneElement | Advance Directives Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:advance_directive_entry | S C | 0..* | Reference(Consent) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:assessment_section | S C | 0..1 | BackboneElement | Assessment Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:family_history_section | S C | 0..1 | BackboneElement | Family History Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of family member diseases Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:family_history_entry | S C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:general_status_section | S C | 0..1 | BackboneElement | General Status Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:past_medical_history_section | S C | 0..1 | BackboneElement | Past Medical History Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:past_medical_history_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:history_of_present_illness_section | S C | 0..1 | BackboneElement | History of Present Illness Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:immunizations_section | S C | 0..1 | BackboneElement | Immunizations Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:immunizations_entry | S C | 0..* | Reference(US Core Immunization Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:medical_equipment_section | S C | 0..1 | BackboneElement | Medical Equipment Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medical equipment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medical_equipment_entry | S C | 0..* | Reference(Device | US Core Procedure Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:physical_exam_section | S C | 0..1 | BackboneElement | Physical Exam Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:physical_exam_entry | S C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:procedures_section | S C | 0..1 | BackboneElement | Procedures Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:procedures_entry | S C | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:review_of_systems_section | S C | 0..1 | BackboneElement | Review of Systems Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | This section contains only human readable content This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:social_history_section | S C | 0..1 | BackboneElement | Social History Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Social history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:social_history_entry | S C | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:vital_signs_section | S C | 0..1 | BackboneElement | Vital Signs Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:vital_signs_entry | S C | 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.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:goals_section | S C | 0..1 | BackboneElement | Goals Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Goals Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61146-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:goals_entry | S C | 0..* | Reference(US Core Goal Profile) | entry
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:health_concerns_section | S C | 0..1 | BackboneElement | Health Concerns Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Health concerns section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | S C | 1..1 | Narrative | text This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:health_concerns_entry | S C | 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.
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Composition.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Composition.status | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` From the FHIR Standard
Composition.type | required | ReferralDocumentType `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.2.3` From this IG
Composition.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` From the FHIR Standard
Composition.attester.mode | required | CompositionAttestationMode `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:legal_attester.mode | required | Fixed Value: legal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:professional_attester.mode | required | Fixed Value: professional `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.attester:personal_attester.mode | required | Fixed Value: personal `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` From the FHIR Standard
Composition.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` From the FHIR Standard
Composition.event.code | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode`
Composition.section.code | example | DocumentSectionCodes `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.code | example | Pattern Value: LOINC Code 48765-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:medications_section.code | example | Pattern Value: LOINC Code 10160-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medications_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medications_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medications_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:problem_section.code | example | Pattern Value: LOINC Code 11450-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:problem_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:problem_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:problem_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:reason_for_referral_section.code | example | Pattern Value: LOINC Code 42349-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:reason_for_referral_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:reason_for_referral_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:reason_for_referral_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:functional_status_section.code | example | Pattern Value: LOINC Code 47420-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:functional_status_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:functional_status_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:functional_status_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:mental_status_section.code | example | Pattern Value: LOINC Code 10190-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:mental_status_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:mental_status_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:mental_status_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:nutrition_section.code | example | Pattern Value: LOINC Code 61144-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:nutrition_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:nutrition_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:nutrition_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:plan_of_treatment_section.code | example | Pattern Value: LOINC Code 18776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:plan_of_treatment_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:results_section.code | example | Pattern Value: LOINC Code 30954-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:results_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:results_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:results_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:assessment_and_plan_section.code | example | Pattern Value: LOINC Code 51847-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_and_plan_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:advance_directives_section.code | example | Pattern Value: LOINC Code 42348-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:advance_directives_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:advance_directives_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:advance_directives_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:assessment_section.code | example | Pattern Value: LOINC Code 51848-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:assessment_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:assessment_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:family_history_section.code | example | Pattern Value: LOINC Code 10157-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:family_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:family_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:family_history_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:general_status_section.code | example | Pattern Value: LOINC Code 10210-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:general_status_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:general_status_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:general_status_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:past_medical_history_section.code | example | Pattern Value: LOINC Code 11348-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:past_medical_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:past_medical_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:past_medical_history_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:history_of_present_illness_section.code | example | Pattern Value: LOINC Code 10164-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:history_of_present_illness_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:history_of_present_illness_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:history_of_present_illness_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:immunizations_section.code | example | Pattern Value: LOINC Code 11369-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:immunizations_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:immunizations_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:immunizations_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:medical_equipment_section.code | example | Pattern Value: LOINC Code 46264-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medical_equipment_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medical_equipment_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medical_equipment_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:physical_exam_section.code | example | Pattern Value: LOINC Code 29545-1 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:physical_exam_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedures_section.code | example | Pattern Value: LOINC Code 47519-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedures_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedures_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedures_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:review_of_systems_section.code | example | Pattern Value: LOINC Code 10187-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:review_of_systems_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:social_history_section.code | example | Pattern Value: LOINC Code 29762-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:social_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:social_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:social_history_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:vital_signs_section.code | example | Pattern Value: LOINC Code 8716-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:vital_signs_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:goals_section.code | example | Pattern Value: LOINC Code 61146-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:goals_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:goals_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:goals_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:health_concerns_section.code | example | Pattern Value: LOINC Code 75310-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:health_concerns_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:health_concerns_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:health_concerns_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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:allergies_and_intolerances_section, Composition.section:medications_section, Composition.section:problem_section, Composition.section:reason_for_referral_section, Composition.section:functional_status_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:results_section, Composition.section:assessment_and_plan_section, Composition.section:advance_directives_section, Composition.section:assessment_section, Composition.section:family_history_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:physical_exam_section, Composition.section:procedures_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:goals_section, Composition.section:health_concerns_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: 16 elements(63 nested mandatory elements)
Must-Support: 119 elements

Structures

This structure refers to these other structures:

- US Core AllergyIntolerance Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance)
- US Core Medication Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication)
- US Core MedicationRequest Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest)
- US Core Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
- US Core Goal Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal)
- US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)
- US Core Laboratory Result Observation Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab)
- US Core Immunization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization)
- US Core Procedure Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure)
- US Core Smoking Status Observation Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus)
- Vital Signs Profile (http://hl7.org/fhir/StructureDefinition/vitalsigns)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Composition.section
- The element 1 is sliced based on the value of Composition.section.entry

Other representations of profile: CSV, Excel, Schematron