Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build United States of America

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Physical Exam Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.2.10 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: PhysicalExamSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.2.10:2015-08-01

The section includes direct observations made by a clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body.

It also includes observations made by the examining clinician using only inspection, palpation, auscultation, and percussion. It does not include laboratory or imaging findings.

The exam may be limited to pertinent body systems based on the patient’s chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically.

The Physical Exam Section may contain multiple nested subsections.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionBase for all types and resources
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by value:observation
.... entry:longCareWound 0..*Element
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:component1 0..*Element
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text 1..1xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.component:component1.section.codepreferredPhysical Exam Type
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionBase for all types and resources
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C0..*ElementSlice: Unordered, Open by value:observation
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entry:longCareWound C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
.... component:component1 0..*Element
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text S1..1xhtml

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType
Section.component:component1.section.classCoderequiredFixed Value: DOCSECT
Section.component:component1.section.moodCoderequiredFixed Value: EVN
Section.component:component1.section.codepreferredPhysical Exam Type

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
only-one-statementerrorSection.entry, Section.entry:longCareWoundSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry C0..*ElementSlice: Unordered, Open by value:observation
.... entry:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:longCareWound C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
.... component:component1 0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
...... ID 0..1string
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..1II
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text S1..1xhtml
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... subject 0..1Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
....... relatedSubject 1..1RelatedSubject
...... author 0..*Author
...... informant 0..*Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... assignedEntity 0..1AssignedEntity
....... relatedEntity 0..1RelatedEntity
...... entry C0..*Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1code
....... contextConductionInd 1..1boolean
....... (Choice of one) 1..1
........ observation 0..1Observation
........ regionOfInterest 0..1RegionOfInterest
........ observationMedia 0..1ObservationMedia
........ substanceAdministration 0..1SubstanceAdministration
........ supply 0..1Supply
........ procedure 0..1Procedure
........ encounter 0..1Encounter
........ organizer 0..1Organizer
........ act 0..1Act
...... component 0..*Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP
Section.component:component1.section.nullFlavorrequiredNullFlavor
Section.component:component1.section.classCoderequiredFixed Value: DOCSECT
Section.component:component1.section.moodCoderequiredFixed Value: EVN
Section.component:component1.section.codepreferredPhysical Exam Type
Section.component:component1.section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.component:component1.section.subject.typeCoderequiredFixed Value: SBJ
Section.component:component1.section.subject.contextControlCoderequiredFixed Value: OP
Section.component:component1.section.subject.awarenessCodeextensibleTargetAwareness
Section.component:component1.section.informant.typeCoderequiredFixed Value: INF
Section.component:component1.section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
only-one-statementerrorSection.entry, Section.entry:longCareWound, Section.component:component1.section.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (5 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of value:observation
  • The element Section.component is sliced based on the value of value:section

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionBase for all types and resources
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by value:observation
.... entry:longCareWound 0..*Element
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:component1 0..*Element
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text 1..1xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.component:component1.section.codepreferredPhysical Exam Type

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionBase for all types and resources
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C0..*ElementSlice: Unordered, Open by value:observation
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entry:longCareWound C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
.... component:component1 0..*Element
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text S1..1xhtml

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType
Section.component:component1.section.classCoderequiredFixed Value: DOCSECT
Section.component:component1.section.moodCoderequiredFixed Value: EVN
Section.component:component1.section.codepreferredPhysical Exam Type

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
only-one-statementerrorSection.entry, Section.entry:longCareWoundSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry C0..*ElementSlice: Unordered, Open by value:observation
.... entry:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:longCareWound C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
.... component:component1 0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
...... ID 0..1string
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..1II
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text S1..1xhtml
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... subject 0..1Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
....... relatedSubject 1..1RelatedSubject
...... author 0..*Author
...... informant 0..*Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... assignedEntity 0..1AssignedEntity
....... relatedEntity 0..1RelatedEntity
...... entry C0..*Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1code
....... contextConductionInd 1..1boolean
....... (Choice of one) 1..1
........ observation 0..1Observation
........ regionOfInterest 0..1RegionOfInterest
........ observationMedia 0..1ObservationMedia
........ substanceAdministration 0..1SubstanceAdministration
........ supply 0..1Supply
........ procedure 0..1Procedure
........ encounter 0..1Encounter
........ organizer 0..1Organizer
........ act 0..1Act
...... component 0..*Element
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP
Section.component:component1.section.nullFlavorrequiredNullFlavor
Section.component:component1.section.classCoderequiredFixed Value: DOCSECT
Section.component:component1.section.moodCoderequiredFixed Value: EVN
Section.component:component1.section.codepreferredPhysical Exam Type
Section.component:component1.section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.component:component1.section.subject.typeCoderequiredFixed Value: SBJ
Section.component:component1.section.subject.contextControlCoderequiredFixed Value: OP
Section.component:component1.section.subject.awarenessCodeextensibleTargetAwareness
Section.component:component1.section.informant.typeCoderequiredFixed Value: INF
Section.component:component1.section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
only-one-statementerrorSection.entry, Section.entry:longCareWound, Section.component:component1.section.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (5 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of value:observation
  • The element Section.component is sliced based on the value of value:section

 

​Other representations of profile: CSV, Excel, Schematron