Specialty Eyecare CDA Implementation Guide
0.1.0 - ci-build

Specialty Eyecare CDA Implementation Guide, published by Dogwood Health Consulting. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cda-eyecare/ and changes regularly. See the Directory of published versions

Logical Model: EyecareExamSection

Official URL: http://hl7.org/cda/us/eyecare/StructureDefinition/EyecareExamSection Version: 0.1.0
Draft as of 2024-02-07 Computable Name: EyecareExamSection

A constraint on Physical Exam Section that allows for specific eyecare exams.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1PhysicalExamSectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component, templateId, templateId, code, title, text, entry, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 1..*EntrySlice: Unordered, Open by profile:observation
.... entry:resultOrganizer 1..1Entry
..... organizer C0..1VisualAcuityOrganizer, RefractionOrganizer, DiagnosticAssessmentEyeTestOrganizer, PosteriorSegmentOrganizerBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observation, Section.entry:resultOrganizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1PhysicalExamSectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component, templateId, templateId, code, title, text, entry, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 1..*EntrySlice: Unordered, Open by profile:observation
.... entry:resultOrganizer 1..1Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer C0..1VisualAcuityOrganizer, RefractionOrganizer, DiagnosticAssessmentEyeTestOrganizer, PosteriorSegmentOrganizerBase for all types and resources
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @ID 0..1xs:ID
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..1II
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... subject 0..1Subject
..... author 0..*Author
..... informant 0..*Informant
..... entry 0..*Entry
..... component 0..*InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csFixed Value: COMP
...... @contextConductionInd 0..1blFixed Value: true
...... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-ActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:resultOrganizer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:resultOrganizer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:resultOrganizer.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.component.section.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-ActMood
Section.component.section.codepreferredPhysical Exam Type
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
Section.component.section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observation, Section.entry:resultOrganizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

Differential View

This structure is derived from PhysicalExamSection

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1PhysicalExamSectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component, templateId, templateId, code, title, text, entry, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 1..*EntrySlice: Unordered, Open by profile:observation
.... entry:resultOrganizer 1..1Entry
..... organizer C0..1VisualAcuityOrganizer, RefractionOrganizer, DiagnosticAssessmentEyeTestOrganizer, PosteriorSegmentOrganizerBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observation, Section.entry:resultOrganizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1PhysicalExamSectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component, templateId, templateId, code, title, text, entry, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 1..*EntrySlice: Unordered, Open by profile:observation
.... entry:resultOrganizer 1..1Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer C0..1VisualAcuityOrganizer, RefractionOrganizer, DiagnosticAssessmentEyeTestOrganizer, PosteriorSegmentOrganizerBase for all types and resources
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @ID 0..1xs:ID
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..1II
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... subject 0..1Subject
..... author 0..*Author
..... informant 0..*Informant
..... entry 0..*Entry
..... component 0..*InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csFixed Value: COMP
...... @contextConductionInd 0..1blFixed Value: true
...... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-ActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:resultOrganizer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:resultOrganizer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:resultOrganizer.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.component.section.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-ActMood
Section.component.section.codepreferredPhysical Exam Type
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
Section.component.section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observation, Section.entry:resultOrganizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

 

Other representations of profile: CSV, Excel