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: Procedure Note

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

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.

> 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/Procedure-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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (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
event | S Σ | 1..* | BackboneElement | serviceEvent
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
period | Σ | 1..1 | Period | period
start | Σ C | 1..1 | dateTime | start
end | Σ C | 1..1 | dateTime | end
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:complications_section | S C | 1..1 | BackboneElement | Complications 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 | Complications 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: 55109-3
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:complications_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_description_section | S C | 1..1 | BackboneElement | Procedure Description 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 | Procedure description 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: 29554-3
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:procedure_indications_section | S C | 1..1 | BackboneElement | Procedure Indications 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 | Procedure indications 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: 59768-2
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:postprocedure_diagnosis_section | S C | 1..1 | BackboneElement | Postprocedure Diagnosis 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 | Postprocedure diagnosis 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: 59769-0
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 | S C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:postprocedure_diagnosis_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:allergies_and_intolerances_section | S C | 0..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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: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 | Assessments 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:assessment_and_plan_section | S C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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 | 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: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:anesthesia_section | S C | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia 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: 59774-0
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:anesthesia_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section
section:chief_complaint_and_reason_for_visit_section | S C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 46239-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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:chief_complaint_section | S C | 0..1 | BackboneElement | Chief Complaint Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 10154-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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 | 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: 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: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 | 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: 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:medical_history_section | S C | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) 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: 11329-0
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:medications_section | S C | 0..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 | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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:medications_administered_section | S C | 0..1 | BackboneElement | Medications Administered 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 | Medications administered 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: 29549-3
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:medications_administered_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
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 | Physical findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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: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:planned_procedure_section | S C | 0..1 | BackboneElement | Planned Procedure 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 | Planned procedure 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: 59772-4
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
section:procedure_disposition_section | S C | 0..1 | BackboneElement | Procedure Disposition 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 | Procedure disposition 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: 59775-7
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 | 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:procedure_estimated_blood_loss_section | S C | 0..1 | BackboneElement | Procedure Estimated Blood Loss 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 | Procedure estimated blood loss 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: 59770-8
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 | 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:procedure_findings_section | S C | 0..1 | BackboneElement | Procedure Findings 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 | Procedure findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5
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 | 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:procedure_implants_section | S C | 0..1 | BackboneElement | Procedure Implants 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 | Procedure implants 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: 59771-6
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 | 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:procedure_specimens_taken_section | S C | 0..1 | BackboneElement | Procedure Specimens Taken 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 | Procedure specimens taken 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: 59773-2
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: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:reason_for_visit_section | S C | 0..1 | BackboneElement | Reason for Visit Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 29299-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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: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 | Review of systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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
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 | ProcedureNoteDocumentTypeCodes `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1` 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:complications_section.code | example | Pattern Value: LOINC Code 55109-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.code | example | Pattern Value: LOINC Code 59769-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` 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: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_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:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern Value: LOINC Code 46239-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_section.code | example | Pattern Value: LOINC Code 10154-3 `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: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:medical_history_section.code | example | Pattern Value: LOINC Code 11329-0 `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:medications_administered_section.code | example | Pattern Value: LOINC Code 29549-3 `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: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:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2 `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:reason_for_visit_section.code | example | Pattern Value: LOINC Code 29299-5 `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

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required)
event | S | 1..* | BackboneElement | serviceEvent
period |  | 1..1 | Period | period
start |  | 1..1 | dateTime | start
end |  | 1..1 | dateTime | end
Slices for section |  | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code
section:complications_section | S | 1..1 | BackboneElement | Complications Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Complications 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: 55109-3
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:complications_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_description_section | S | 1..1 | BackboneElement | Procedure Description Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure description 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: 29554-3
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_indications_section | S | 1..1 | BackboneElement | Procedure Indications Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure indications 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: 59768-2
text | S | 1..1 | Narrative | This section contains only human readable content
section:postprocedure_diagnosis_section | S | 1..1 | BackboneElement | Postprocedure Diagnosis Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Postprocedure diagnosis 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: 59769-0
text | S | 1..1 | Narrative | text
Slices for entry | S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:postprocedure_diagnosis_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:allergies_and_intolerances_section | S | 0..1 | BackboneElement | Allergies and Intolerances Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:allergies_and_intolerances_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | 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 | Assessments 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:assessment_and_plan_section | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
title | 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 | 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: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:anesthesia_section | S | 0..1 | BackboneElement | Anesthesia Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Anesthesia 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: 59774-0
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:anesthesia_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section
section:chief_complaint_and_reason_for_visit_section | S | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
title | 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: 46239-0
text | S | 1..1 | Narrative | This section contains only human readable content
section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint 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: 10154-3
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 | 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: 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:past_medical_history_section | S | 0..1 | BackboneElement | Past Medical History 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: 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:medical_history_section | S | 0..1 | BackboneElement | Medical (General) History Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medical (general) 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: 11329-0
text | S | 1..1 | Narrative | This section contains only human readable content
section:medications_section | S | 0..1 | BackboneElement | Medications Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
text | 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:medications_administered_section | S | 0..1 | BackboneElement | Medications Administered Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medications administered 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: 29549-3
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medications_administered_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
section:physical_exam_section | S | 0..1 | BackboneElement | Physical Exam Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Physical findings Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
text | 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: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:planned_procedure_section | S | 0..1 | BackboneElement | Planned Procedure Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Planned procedure 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: 59772-4
text | S | 1..1 | Narrative | text
section:procedure_disposition_section | S | 0..1 | BackboneElement | Procedure Disposition Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure disposition 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: 59775-7
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_estimated_blood_loss_section | S | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure estimated blood loss 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: 59770-8
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_findings_section | S | 0..1 | BackboneElement | Procedure Findings Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure findings Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_implants_section | S | 0..1 | BackboneElement | Procedure Implants Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure implants 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: 59771-6
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_specimens_taken_section | S | 0..1 | BackboneElement | Procedure Specimens Taken Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure specimens taken 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: 59773-2
text | S | 1..1 | Narrative | This section contains only human readable content
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:reason_for_visit_section | S | 0..1 | BackboneElement | Reason for Visit 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: 29299-5
text | S | 1..1 | Narrative | This section contains only human readable content
section:review_of_systems_section | S | 0..1 | BackboneElement | Review of Systems Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Review of systems Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
text | 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
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Composition.type | required | ProcedureNoteDocumentTypeCodes `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1` 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (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 | S Σ | 1..* | BackboneElement | serviceEvent
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 | 1..1 | Period | period
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | Σ C | 1..1 | dateTime | start
end | Σ C | 1..1 | dateTime | end
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:complications_section | S C | 1..1 | BackboneElement | Complications 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 | Complications 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: 55109-3
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:complications_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:procedure_description_section | S C | 1..1 | BackboneElement | Procedure Description 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 | Procedure description 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: 29554-3
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:procedure_indications_section | S C | 1..1 | BackboneElement | Procedure Indications 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 | Procedure indications 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: 59768-2
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:postprocedure_diagnosis_section | S C | 1..1 | BackboneElement | Postprocedure Diagnosis 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 | Postprocedure diagnosis 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: 59769-0
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 | S C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:postprocedure_diagnosis_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:allergies_and_intolerances_section | S C | 0..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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: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 | Assessments 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:assessment_and_plan_section | S C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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 | 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: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:anesthesia_section | S C | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia 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: 59774-0
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:anesthesia_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | 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:chief_complaint_and_reason_for_visit_section | S C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 46239-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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:chief_complaint_section | S C | 0..1 | BackboneElement | Chief Complaint Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 10154-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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 | 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: 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: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 | 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: 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:medical_history_section | S C | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) 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: 11329-0
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:medications_section | S C | 0..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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:medications_administered_section | S C | 0..1 | BackboneElement | Medications Administered 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 | Medications administered 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: 29549-3
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:medications_administered_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: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 | Physical findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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: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:planned_procedure_section | S C | 0..1 | BackboneElement | Planned Procedure 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 | Planned procedure 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: 59772-4
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.
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:procedure_disposition_section | S C | 0..1 | BackboneElement | Procedure Disposition 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 | Procedure disposition 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: 59775-7
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 | 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:procedure_estimated_blood_loss_section | S C | 0..1 | BackboneElement | Procedure Estimated Blood Loss 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 | Procedure estimated blood loss 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: 59770-8
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 | 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:procedure_findings_section | S C | 0..1 | BackboneElement | Procedure Findings 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 | Procedure findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5
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 | 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:procedure_implants_section | S C | 0..1 | BackboneElement | Procedure Implants 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 | Procedure implants 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: 59771-6
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 | 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:procedure_specimens_taken_section | S C | 0..1 | BackboneElement | Procedure Specimens Taken 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 | Procedure specimens taken 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: 59773-2
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: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:reason_for_visit_section | S C | 0..1 | BackboneElement | Reason for Visit Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 29299-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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: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 | Review of systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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
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 | ProcedureNoteDocumentTypeCodes `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1` 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:complications_section.code | example | Pattern Value: LOINC Code 55109-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:complications_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:complications_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:complications_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_description_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_description_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_description_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_indications_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_indications_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_indications_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.code | example | Pattern Value: LOINC Code 59769-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:postprocedure_diagnosis_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: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: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:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:anesthesia_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:anesthesia_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:anesthesia_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern Value: LOINC Code 46239-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:chief_complaint_section.code | example | Pattern Value: LOINC Code 10154-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:chief_complaint_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: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:medical_history_section.code | example | Pattern Value: LOINC Code 11329-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medical_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medical_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medical_history_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:medications_administered_section.code | example | Pattern Value: LOINC Code 29549-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medications_administered_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medications_administered_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medications_administered_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: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:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:planned_procedure_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:planned_procedure_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:planned_procedure_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_disposition_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_disposition_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_disposition_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_findings_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_findings_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_findings_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_implants_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_implants_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_implants_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_specimens_taken_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:reason_for_visit_section.code | example | Pattern Value: LOINC Code 29299-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:reason_for_visit_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:reason_for_visit_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:reason_for_visit_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

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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: 20 elements(72 nested mandatory elements)
Must-Support: 127 elements

Structures

This structure refers to these other structures:

- US Core Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
- 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 Procedure Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure)
- 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 Smoking Status Observation Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus)

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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (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
event | S Σ | 1..* | BackboneElement | serviceEvent
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
period | Σ | 1..1 | Period | period
start | Σ C | 1..1 | dateTime | start
end | Σ C | 1..1 | dateTime | end
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:complications_section | S C | 1..1 | BackboneElement | Complications 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 | Complications 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: 55109-3
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:complications_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_description_section | S C | 1..1 | BackboneElement | Procedure Description 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 | Procedure description 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: 29554-3
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:procedure_indications_section | S C | 1..1 | BackboneElement | Procedure Indications 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 | Procedure indications 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: 59768-2
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:postprocedure_diagnosis_section | S C | 1..1 | BackboneElement | Postprocedure Diagnosis 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 | Postprocedure diagnosis 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: 59769-0
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 | S C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:postprocedure_diagnosis_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:allergies_and_intolerances_section | S C | 0..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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: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 | Assessments 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:assessment_and_plan_section | S C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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 | 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: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:anesthesia_section | S C | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia 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: 59774-0
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:anesthesia_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section
section:chief_complaint_and_reason_for_visit_section | S C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 46239-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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:chief_complaint_section | S C | 0..1 | BackboneElement | Chief Complaint Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 10154-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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 | 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: 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: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 | 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: 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:medical_history_section | S C | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) 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: 11329-0
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:medications_section | S C | 0..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 | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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:medications_administered_section | S C | 0..1 | BackboneElement | Medications Administered 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 | Medications administered 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: 29549-3
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:medications_administered_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
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 | Physical findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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: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:planned_procedure_section | S C | 0..1 | BackboneElement | Planned Procedure 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 | Planned procedure 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: 59772-4
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
section:procedure_disposition_section | S C | 0..1 | BackboneElement | Procedure Disposition 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 | Procedure disposition 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: 59775-7
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 | 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:procedure_estimated_blood_loss_section | S C | 0..1 | BackboneElement | Procedure Estimated Blood Loss 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 | Procedure estimated blood loss 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: 59770-8
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 | 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:procedure_findings_section | S C | 0..1 | BackboneElement | Procedure Findings 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 | Procedure findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5
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 | 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:procedure_implants_section | S C | 0..1 | BackboneElement | Procedure Implants 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 | Procedure implants 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: 59771-6
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 | 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:procedure_specimens_taken_section | S C | 0..1 | BackboneElement | Procedure Specimens Taken 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 | Procedure specimens taken 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: 59773-2
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: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:reason_for_visit_section | S C | 0..1 | BackboneElement | Reason for Visit Section Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 29299-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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: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 | Review of systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | 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
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 | ProcedureNoteDocumentTypeCodes `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1` 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:complications_section.code | example | Pattern Value: LOINC Code 55109-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.code | example | Pattern Value: LOINC Code 59769-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` 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: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_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:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern Value: LOINC Code 46239-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_section.code | example | Pattern Value: LOINC Code 10154-3 `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: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:medical_history_section.code | example | Pattern Value: LOINC Code 11329-0 `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:medications_administered_section.code | example | Pattern Value: LOINC Code 29549-3 `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: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:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2 `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:reason_for_visit_section.code | example | Pattern Value: LOINC Code 29299-5 `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

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required)
event | S | 1..* | BackboneElement | serviceEvent
period |  | 1..1 | Period | period
start |  | 1..1 | dateTime | start
end |  | 1..1 | dateTime | end
Slices for section |  | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code
section:complications_section | S | 1..1 | BackboneElement | Complications Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Complications 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: 55109-3
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:complications_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_description_section | S | 1..1 | BackboneElement | Procedure Description Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure description 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: 29554-3
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_indications_section | S | 1..1 | BackboneElement | Procedure Indications Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure indications 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: 59768-2
text | S | 1..1 | Narrative | This section contains only human readable content
section:postprocedure_diagnosis_section | S | 1..1 | BackboneElement | Postprocedure Diagnosis Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Postprocedure diagnosis 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: 59769-0
text | S | 1..1 | Narrative | text
Slices for entry | S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:postprocedure_diagnosis_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:allergies_and_intolerances_section | S | 0..1 | BackboneElement | Allergies and Intolerances Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:allergies_and_intolerances_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | 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 | Assessments 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:assessment_and_plan_section | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
title | 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 | 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: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:anesthesia_section | S | 0..1 | BackboneElement | Anesthesia Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Anesthesia 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: 59774-0
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:anesthesia_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section
section:chief_complaint_and_reason_for_visit_section | S | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
title | 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: 46239-0
text | S | 1..1 | Narrative | This section contains only human readable content
section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint 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: 10154-3
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 | 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: 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:past_medical_history_section | S | 0..1 | BackboneElement | Past Medical History 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: 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:medical_history_section | S | 0..1 | BackboneElement | Medical (General) History Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medical (general) 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: 11329-0
text | S | 1..1 | Narrative | This section contains only human readable content
section:medications_section | S | 0..1 | BackboneElement | Medications Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
text | 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:medications_administered_section | S | 0..1 | BackboneElement | Medications Administered Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Medications administered 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: 29549-3
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:medications_administered_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section
section:physical_exam_section | S | 0..1 | BackboneElement | Physical Exam Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Physical findings Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
text | 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: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:planned_procedure_section | S | 0..1 | BackboneElement | Planned Procedure Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Planned procedure 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: 59772-4
text | S | 1..1 | Narrative | text
section:procedure_disposition_section | S | 0..1 | BackboneElement | Procedure Disposition Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure disposition 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: 59775-7
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_estimated_blood_loss_section | S | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure estimated blood loss 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: 59770-8
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_findings_section | S | 0..1 | BackboneElement | Procedure Findings Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure findings Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_implants_section | S | 0..1 | BackboneElement | Procedure Implants Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure implants 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: 59771-6
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_specimens_taken_section | S | 0..1 | BackboneElement | Procedure Specimens Taken Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Procedure specimens taken 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: 59773-2
text | S | 1..1 | Narrative | This section contains only human readable content
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:reason_for_visit_section | S | 0..1 | BackboneElement | Reason for Visit 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: 29299-5
text | S | 1..1 | Narrative | This section contains only human readable content
section:review_of_systems_section | S | 0..1 | BackboneElement | Review of Systems Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Review of systems Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
text | 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
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Composition.type | required | ProcedureNoteDocumentTypeCodes `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1` 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (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 | S Σ | 1..* | BackboneElement | serviceEvent
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 | 1..1 | Period | period
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | Σ C | 1..1 | dateTime | start
end | Σ C | 1..1 | dateTime | end
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:complications_section | S C | 1..1 | BackboneElement | Complications 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 | Complications 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: 55109-3
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:complications_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:procedure_description_section | S C | 1..1 | BackboneElement | Procedure Description 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 | Procedure description 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: 29554-3
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:procedure_indications_section | S C | 1..1 | BackboneElement | Procedure Indications 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 | Procedure indications 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: 59768-2
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:postprocedure_diagnosis_section | S C | 1..1 | BackboneElement | Postprocedure Diagnosis 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 | Postprocedure diagnosis 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: 59769-0
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 | S C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:postprocedure_diagnosis_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:allergies_and_intolerances_section | S C | 0..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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: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 | Assessments 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:assessment_and_plan_section | S C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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 | 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: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:anesthesia_section | S C | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia 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: 59774-0
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:anesthesia_entry | S C | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | 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:chief_complaint_and_reason_for_visit_section | S C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 46239-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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:chief_complaint_section | S C | 0..1 | BackboneElement | Chief Complaint Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 10154-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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 | 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: 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: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 | 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: 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:medical_history_section | S C | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) 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: 11329-0
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:medications_section | S C | 0..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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:medications_administered_section | S C | 0..1 | BackboneElement | Medications Administered 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 | Medications administered 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: 29549-3
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:medications_administered_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: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 | Physical findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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: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:planned_procedure_section | S C | 0..1 | BackboneElement | Planned Procedure 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 | Planned procedure 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: 59772-4
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.
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:procedure_disposition_section | S C | 0..1 | BackboneElement | Procedure Disposition 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 | Procedure disposition 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: 59775-7
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 | 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:procedure_estimated_blood_loss_section | S C | 0..1 | BackboneElement | Procedure Estimated Blood Loss 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 | Procedure estimated blood loss 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: 59770-8
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 | 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:procedure_findings_section | S C | 0..1 | BackboneElement | Procedure Findings 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 | Procedure findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59776-5
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 | 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:procedure_implants_section | S C | 0..1 | BackboneElement | Procedure Implants 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 | Procedure implants 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: 59771-6
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 | 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:procedure_specimens_taken_section | S C | 0..1 | BackboneElement | Procedure Specimens Taken 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 | Procedure specimens taken 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: 59773-2
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: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:reason_for_visit_section | S C | 0..1 | BackboneElement | Reason for Visit Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | 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: 29299-5
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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: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 | Review of systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | 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
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 | ProcedureNoteDocumentTypeCodes `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1` 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:complications_section.code | example | Pattern Value: LOINC Code 55109-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:complications_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:complications_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:complications_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_description_section.code | example | Pattern Value: LOINC Code 29554-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_description_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_description_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_description_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_indications_section.code | example | Pattern Value: LOINC Code 59768-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_indications_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_indications_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_indications_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.code | example | Pattern Value: LOINC Code 59769-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:postprocedure_diagnosis_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:postprocedure_diagnosis_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: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: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:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:anesthesia_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:anesthesia_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:anesthesia_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern Value: LOINC Code 46239-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:chief_complaint_section.code | example | Pattern Value: LOINC Code 10154-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:chief_complaint_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:chief_complaint_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: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:medical_history_section.code | example | Pattern Value: LOINC Code 11329-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medical_history_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medical_history_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medical_history_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:medications_administered_section.code | example | Pattern Value: LOINC Code 29549-3 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:medications_administered_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:medications_administered_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:medications_administered_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: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:planned_procedure_section.code | example | Pattern Value: LOINC Code 59772-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:planned_procedure_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:planned_procedure_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:planned_procedure_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_disposition_section.code | example | Pattern Value: LOINC Code 59775-7 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_disposition_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_disposition_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_disposition_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.code | example | Pattern Value: LOINC Code 59770-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_estimated_blood_loss_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_findings_section.code | example | Pattern Value: LOINC Code 59776-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_findings_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_findings_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_findings_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_implants_section.code | example | Pattern Value: LOINC Code 59771-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_implants_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_implants_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_implants_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.code | example | Pattern Value: LOINC Code 59773-2 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:procedure_specimens_taken_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:procedure_specimens_taken_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:reason_for_visit_section.code | example | Pattern Value: LOINC Code 29299-5 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:reason_for_visit_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:reason_for_visit_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:reason_for_visit_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

#### Constraints

Id | Grade | Path(s) | Details | Requirements
cmp-1 | error | Composition.section, Composition.section:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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:complications_section, Composition.section:procedure_description_section, Composition.section:procedure_indications_section, Composition.section:postprocedure_diagnosis_section, Composition.section:allergies_and_intolerances_section, Composition.section:assessment_section, Composition.section:assessment_and_plan_section, Composition.section:anesthesia_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:past_medical_history_section, Composition.section:history_of_present_illness_section, Composition.section:medical_history_section, Composition.section:medications_section, Composition.section:medications_administered_section, Composition.section:physical_exam_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_implants_section, Composition.section:procedure_specimens_taken_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_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: 20 elements(72 nested mandatory elements)
Must-Support: 127 elements

Structures

This structure refers to these other structures:

- US Core Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
- 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 Procedure Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure)
- 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 Smoking Status Observation Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus)

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