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: Operative Note

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

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

> 2025 Ballot of C-CDA ↔ FHIR US Core 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/Operative-Note-Example
- CapabilityStatements using this Profile: CCDA on FHIR Client and CCDA on FHIR Server

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Slices for extension |  |  |  | Content/Rules for all slices
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required)
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
attester:legal_attester | S | 0..1 | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
section:anesthesia_section | S C | 1..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: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:preoperative_diagnosis_section | S C | 1..1 | BackboneElement | Preoperative 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 | Preoperative 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: 10219-4
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:preoperative_diagnosis_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_estimated_blood_loss_section | S C | 1..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 | 1..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 | 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:procedure_findings_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_specimens_taken_section | S C | 1..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:postoperative_diagnosis_section | S C | 1..1 | BackboneElement | Postoperative 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 | Postoperative 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: 10218-6
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_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 |  | 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:operative_note_surgical_procedure_section | S C | 0..1 | BackboneElement | Operative Note Surgical 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 | Operative Note Surgical 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: 10223-6
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:operative_note_fluids_section | S C | 0..1 | BackboneElement | Operative Note Fluids 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 | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0
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: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 | S 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
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry | S C | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
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_indications_section | S C | 0..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
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section: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:surgical_drains_section | S C | 0..1 | BackboneElement | Surgical Drains 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 | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8
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
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 | SurgicalOperationNoteDocumentTypeCode `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1` 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:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` 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:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4 `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_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:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6 `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:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0 `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_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_implants_section.code | example | Pattern Value: LOINC Code 59771-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8 `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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from USRealmHeader

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
type | S | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required)
Slices for section |  | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code
section:anesthesia_section | S | 1..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: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:preoperative_diagnosis_section | S | 1..1 | BackboneElement | Preoperative Diagnosis Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Preoperative 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: 10219-4
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:preoperative_diagnosis_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_estimated_blood_loss_section | S | 1..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 | 1..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 | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:procedure_findings_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_specimens_taken_section | S | 1..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:postoperative_diagnosis_section | S | 1..1 | BackboneElement | Postoperative Diagnosis Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Postoperative 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: 10218-6
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_description_section | S | 1..1 | BackboneElement | Procedure Description Section
title |  | 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:operative_note_surgical_procedure_section | S | 0..1 | BackboneElement | Operative Note Surgical Procedure Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Operative Note Surgical 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: 10223-6
text | S | 1..1 | Narrative | This section contains only human readable content
section:operative_note_fluids_section | S | 0..1 | BackboneElement | Operative Note Fluids Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Operative Note Fluids 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: 10216-0
text | S | 1..1 | Narrative | This section contains only human readable content
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 | S | 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
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry | S | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
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_indications_section | S | 0..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
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section: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:surgical_drains_section | S | 0..1 | BackboneElement | Surgical Drains Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Surgical Drains 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: 11537-8
text | S | 1..1 | Narrative | This section contains only human readable content
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Composition.type | required | SurgicalOperationNoteDocumentTypeCode `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1` From this IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required)
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
relatesTo |  | 0..* | BackboneElement | Relationships to other compositions/documents
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x] |  | 1..1 |  | Target of the relationship
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period | Σ | 0..1 | Period | The period covered by the documentation
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 0..1 | string | Label for section (e.g. for ToC)
code |  | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:anesthesia_section | S C | 1..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: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:preoperative_diagnosis_section | S C | 1..1 | BackboneElement | Preoperative 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 | Preoperative 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: 10219-4
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:preoperative_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:procedure_estimated_blood_loss_section | S C | 1..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 | 1..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 | 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:procedure_findings_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_specimens_taken_section | S C | 1..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:postoperative_diagnosis_section | S C | 1..1 | BackboneElement | Postoperative 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 | Postoperative 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: 10218-6
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_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 |  | 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:operative_note_surgical_procedure_section | S C | 0..1 | BackboneElement | Operative Note Surgical 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 | Operative Note Surgical 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: 10223-6
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:operative_note_fluids_section | S C | 0..1 | BackboneElement | Operative Note Fluids 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 | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0
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: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 | S 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.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry | S C | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
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_indications_section | S C | 0..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.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section: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:surgical_drains_section | S C | 0..1 | BackboneElement | Surgical Drains 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 | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8
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
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 | SurgicalOperationNoteDocumentTypeCode `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1` 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: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: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:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:preoperative_diagnosis_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:preoperative_diagnosis_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:preoperative_diagnosis_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_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:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:postoperative_diagnosis_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:postoperative_diagnosis_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:postoperative_diagnosis_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:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:operative_note_fluids_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:operative_note_fluids_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:operative_note_fluids_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_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: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:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:surgical_drains_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:surgical_drains_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:surgical_drains_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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from USRealmHeader

Summary

Mandatory: 32 elements(24 nested mandatory elements)
Must-Support: 71 elements

Structures

This structure refers to these other structures:

- 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 Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
- US Core Goal Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal)
- US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Slices

This structure defines the following Slices:

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

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Slices for extension |  |  |  | Content/Rules for all slices
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required)
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
attester:legal_attester | S | 0..1 | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
section:anesthesia_section | S C | 1..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: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:preoperative_diagnosis_section | S C | 1..1 | BackboneElement | Preoperative 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 | Preoperative 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: 10219-4
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:preoperative_diagnosis_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_estimated_blood_loss_section | S C | 1..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 | 1..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 | 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:procedure_findings_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_specimens_taken_section | S C | 1..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:postoperative_diagnosis_section | S C | 1..1 | BackboneElement | Postoperative 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 | Postoperative 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: 10218-6
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_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 |  | 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:operative_note_surgical_procedure_section | S C | 0..1 | BackboneElement | Operative Note Surgical 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 | Operative Note Surgical 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: 10223-6
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:operative_note_fluids_section | S C | 0..1 | BackboneElement | Operative Note Fluids 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 | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0
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: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 | S 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
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry | S C | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
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_indications_section | S C | 0..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
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section: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:surgical_drains_section | S C | 0..1 | BackboneElement | Surgical Drains 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 | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8
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
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 | SurgicalOperationNoteDocumentTypeCode `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1` 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:anesthesia_section.code | example | Pattern Value: LOINC Code 59774-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` 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:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4 `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_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:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6 `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:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0 `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_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_implants_section.code | example | Pattern Value: LOINC Code 59771-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8 `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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

Differential View

This structure is derived from USRealmHeader

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
type | S | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required)
Slices for section |  | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code
section:anesthesia_section | S | 1..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: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:preoperative_diagnosis_section | S | 1..1 | BackboneElement | Preoperative Diagnosis Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Preoperative 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: 10219-4
text | S | 1..1 | Narrative | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:preoperative_diagnosis_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_estimated_blood_loss_section | S | 1..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 | 1..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 | text
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:procedure_findings_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section:procedure_specimens_taken_section | S | 1..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:postoperative_diagnosis_section | S | 1..1 | BackboneElement | Postoperative Diagnosis Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Postoperative 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: 10218-6
text | S | 1..1 | Narrative | This section contains only human readable content
section:procedure_description_section | S | 1..1 | BackboneElement | Procedure Description Section
title |  | 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:operative_note_surgical_procedure_section | S | 0..1 | BackboneElement | Operative Note Surgical Procedure Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Operative Note Surgical 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: 10223-6
text | S | 1..1 | Narrative | This section contains only human readable content
section:operative_note_fluids_section | S | 0..1 | BackboneElement | Operative Note Fluids Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Operative Note Fluids 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: 10216-0
text | S | 1..1 | Narrative | This section contains only human readable content
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 | S | 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
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry | S | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
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_indications_section | S | 0..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
Slices for entry |  | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
section: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:surgical_drains_section | S | 0..1 | BackboneElement | Surgical Drains Section
title | S | 1..1 | string | title
code | S | 1..1 | CodeableConcept | Surgical Drains 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: 11537-8
text | S | 1..1 | Narrative | This section contains only human readable content
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Composition.type | required | SurgicalOperationNoteDocumentTypeCode `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1` From this IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:versionNumber |  | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
extension:version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
extension:data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
extension:informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
extension:information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
extension:participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
extension:performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
extension:authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
extension:order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..1 | Identifier | identifier
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | type Binding: SurgicalOperationNoteDocumentTypeCode (required)
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition
date | S Σ | 1..1 | dateTime | date
author | S Σ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Document Title
Slices for attester |  | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode |  | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:professional_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party
attester:personal_attester | S | 0..* | BackboneElement | attester
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal
time |  | 0..1 | dateTime | When the composition was attested
party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party
custodian | S Σ | 1..1 | Reference(US Core Organization Profile) | custodian
relatesTo |  | 0..* | BackboneElement | Relationships to other compositions/documents
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x] |  | 1..1 |  | Target of the relationship
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period | Σ | 0..1 | Period | The period covered by the documentation
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title |  | 0..1 | string | Label for section (e.g. for ToC)
code |  | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section
focus |  | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode |  | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section:anesthesia_section | S C | 1..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: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:preoperative_diagnosis_section | S C | 1..1 | BackboneElement | Preoperative 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 | Preoperative 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: 10219-4
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:preoperative_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:procedure_estimated_blood_loss_section | S C | 1..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 | 1..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 | 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:procedure_findings_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_specimens_taken_section | S C | 1..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:postoperative_diagnosis_section | S C | 1..1 | BackboneElement | Postoperative 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 | Postoperative 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: 10218-6
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_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 |  | 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:operative_note_surgical_procedure_section | S C | 0..1 | BackboneElement | Operative Note Surgical 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 | Operative Note Surgical 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: 10223-6
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:operative_note_fluids_section | S C | 0..1 | BackboneElement | Operative Note Fluids 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 | Operative Note Fluids Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10216-0
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: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 | S 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.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:planned_procedure_entry | S C | 0..* | Reference(ServiceRequest) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
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_indications_section | S C | 0..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.
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve()
entry:problem_entry | S C | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section | C | 0..* | See section (Composition) | Nested Section
section: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:surgical_drains_section | S C | 0..1 | BackboneElement | Surgical Drains 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 | Surgical Drains Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11537-8
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
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 | SurgicalOperationNoteDocumentTypeCode `http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1` 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: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: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:preoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10219-4 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:preoperative_diagnosis_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:preoperative_diagnosis_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:preoperative_diagnosis_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_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:postoperative_diagnosis_section.code | example | Pattern Value: LOINC Code 10218-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:postoperative_diagnosis_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:postoperative_diagnosis_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:postoperative_diagnosis_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:operative_note_surgical_procedure_section.code | example | Pattern Value: LOINC Code 10223-6 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:operative_note_surgical_procedure_section.emptyReason | preferred | ListEmptyReasons `http://hl7.org/fhir/ValueSet/list-empty-reason` From the FHIR Standard
Composition.section:operative_note_fluids_section.code | example | Pattern Value: LOINC Code 10216-0 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:operative_note_fluids_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:operative_note_fluids_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:operative_note_fluids_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_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: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:surgical_drains_section.code | example | Pattern Value: LOINC Code 11537-8 `http://hl7.org/fhir/ValueSet/doc-section-codes` From the FHIR Standard
Composition.section:surgical_drains_section.mode | required | ListMode `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` From the FHIR Standard
Composition.section:surgical_drains_section.orderedBy | preferred | ListOrderCodes `http://hl7.org/fhir/ValueSet/list-order` From the FHIR Standard
Composition.section:surgical_drains_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:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() |
cmp-2 | error | Composition.section, Composition.section:anesthesia_section, Composition.section:complications_section, Composition.section:preoperative_diagnosis_section, Composition.section:procedure_estimated_blood_loss_section, Composition.section:procedure_findings_section, Composition.section:procedure_specimens_taken_section, Composition.section:postoperative_diagnosis_section, Composition.section:procedure_description_section, Composition.section:operative_note_surgical_procedure_section, Composition.section:operative_note_fluids_section, Composition.section:plan_of_treatment_section, Composition.section:planned_procedure_section, Composition.section:procedure_disposition_section, Composition.section:procedure_indications_section, Composition.section:procedure_implants_section, Composition.section:surgical_drains_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from USRealmHeader

Summary

Mandatory: 32 elements(24 nested mandatory elements)
Must-Support: 71 elements

Structures

This structure refers to these other structures:

- 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 Condition Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
- US Core Goal Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal)
- US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

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