Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build
United States of America
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 
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.14 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: FunctionalStatusSection | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.14:2014-06-09 | ||||
The Functional Status Section contains observations and assessments of a patient’s physical abilities. A patient’s functional status may include information regarding the patient’s ability to perform Activities of Daily Living (ADLs) in areas such as Mobility (e.g., ambulation), Self-Care (e.g., bathing, dressing, feeding, grooming) or Instrumental Activities of Daily Living (IADLs) (e.g., shopping, using a telephone, balancing a check book). Problems that impact function (e.g., dyspnea, dysphagia) can be contained in the section.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
| Path | Conformance | ValueSet / Code |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.code | extensible | DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| only-one-statement | error | Section.entry, Section.entry:funcStatusOrganizer, Section.entry:funcStatusObs, Section.entry:caregiverCharacteristics, Section.entry:assessmentScale, Section.entry:nonMedSupply, Section.entry:selfCareActivity, Section.entry:sensoryStatus, Section.entry:cognitiveStatusProb, Section.entry:functionalStatusProb, Section.entry:pressureUlcer | SHALL 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 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Section | 1..1 | CDAR2.Section | Base for all types and resources | |
  ID | 0..1 | string | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| classCode | 1..1 | code | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:primary | 1..1 | II | ||
  nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.14 | |
  extension | 1..1 | string | Required Pattern: 2014-06-09 | |
 id | 0..1 | II | ||
| code | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 47420-5 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
 translation | 0..* | CD | ||
| title | 1..1 | ED | ||
| text | S | 1..1 | xhtml | |
| confidentialityCode | 0..1 | CE | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
 subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| author | 0..* | Author | ||
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| Slices for entry | C | 0..* | Element | Slice: Unordered, Open by profile:organizer, profile:observation, profile:supply |
 entry: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 Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
 (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
 act | 0..1 | Act | ||
| entry:funcStatusOrganizer | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| organizer | 1..1 | FunctionalStatusOrganizer | Base for all types and resources | |
| entry:funcStatusObs | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | FunctionalStatusObservation | Base for all types and resources | |
| entry:caregiverCharacteristics | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CaregiverCharacteristics | Base for all types and resources | |
| entry:assessmentScale | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| entry:nonMedSupply | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| supply | 1..1 | NonMedicinalSupplyActivity | Base for all types and resources | |
| entry:selfCareActivity | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entry:sensoryStatus | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SensoryStatus | Base for all types and resources | |
| entry:cognitiveStatusProb | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CognitiveStatusProblemObservation | Base for all types and resources | |
| entry:functionalStatusProb | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | FunctionalStatusProblemObservation | Base for all types and resources | |
| entry:pressureUlcer | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PressureUlcerObservation | Base for all types and resources | |
 component | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Fixed Value: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| section | 1..1 | Section | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Section.nullFlavor | required | NullFlavor |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.templateId:primary.nullFlavor | required | NullFlavor |
| Section.code | extensible | DocumentSectionType |
| Section.code.nullFlavor | required | NullFlavor |
| Section.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Section.subject.typeCode | required | Fixed Value: SBJ |
| Section.subject.contextControlCode | required | Fixed Value: OP |
| Section.subject.awarenessCode | extensible | TargetAwareness |
| Section.informant.typeCode | required | Fixed Value: INF |
| Section.informant.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| only-one-statement | error | Section.entry, Section.entry:funcStatusOrganizer, Section.entry:funcStatusObs, Section.entry:caregiverCharacteristics, Section.entry:assessmentScale, Section.entry:nonMedSupply, Section.entry:selfCareActivity, Section.entry:sensoryStatus, Section.entry:cognitiveStatusProb, Section.entry:functionalStatusProb, Section.entry:pressureUlcer | SHALL 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 (10 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
Key Elements View
| Path | Conformance | ValueSet / Code |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.code | extensible | DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| only-one-statement | error | Section.entry, Section.entry:funcStatusOrganizer, Section.entry:funcStatusObs, Section.entry:caregiverCharacteristics, Section.entry:assessmentScale, Section.entry:nonMedSupply, Section.entry:selfCareActivity, Section.entry:sensoryStatus, Section.entry:cognitiveStatusProb, Section.entry:functionalStatusProb, Section.entry:pressureUlcer | SHALL 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
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section | 1..1 | CDAR2.Section | Base for all types and resources | |
| ID | 0..1 | string | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| classCode | 1..1 | code | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.14 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 0..1 | II | ||
| code | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 47420-5 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| title | 1..1 | ED | ||
| text | S | 1..1 | xhtml | |
| confidentialityCode | 0..1 | CE | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| author | 0..* | Author | ||
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| Slices for entry | C | 0..* | Element | Slice: Unordered, Open by profile:organizer, profile:observation, profile:supply |
| entry: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 Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entry:funcStatusOrganizer | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| organizer | 1..1 | FunctionalStatusOrganizer | Base for all types and resources | |
| entry:funcStatusObs | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | FunctionalStatusObservation | Base for all types and resources | |
| entry:caregiverCharacteristics | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CaregiverCharacteristics | Base for all types and resources | |
| entry:assessmentScale | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| entry:nonMedSupply | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| supply | 1..1 | NonMedicinalSupplyActivity | Base for all types and resources | |
| entry:selfCareActivity | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entry:sensoryStatus | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SensoryStatus | Base for all types and resources | |
| entry:cognitiveStatusProb | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CognitiveStatusProblemObservation | Base for all types and resources | |
| entry:functionalStatusProb | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | FunctionalStatusProblemObservation | Base for all types and resources | |
| entry:pressureUlcer | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PressureUlcerObservation | Base for all types and resources | |
| component | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Fixed Value: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| section | 1..1 | Section | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Section.nullFlavor | required | NullFlavor |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.templateId:primary.nullFlavor | required | NullFlavor |
| Section.code | extensible | DocumentSectionType |
| Section.code.nullFlavor | required | NullFlavor |
| Section.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Section.subject.typeCode | required | Fixed Value: SBJ |
| Section.subject.contextControlCode | required | Fixed Value: OP |
| Section.subject.awarenessCode | extensible | TargetAwareness |
| Section.informant.typeCode | required | Fixed Value: INF |
| Section.informant.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| only-one-statement | error | Section.entry, Section.entry:funcStatusOrganizer, Section.entry:funcStatusObs, Section.entry:caregiverCharacteristics, Section.entry:assessmentScale, Section.entry:nonMedSupply, Section.entry:selfCareActivity, Section.entry:sensoryStatus, Section.entry:cognitiveStatusProb, Section.entry:functionalStatusProb, Section.entry:pressureUlcer | SHALL 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 (10 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1.0-draft1 based on FHIR 5.0.0-snapshot3. Generated 2023-01-16
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