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: Results Section - entries required

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.3.1 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: ResultsSectionEntriesRequired
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.3.1:2015-08-01

The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. These coded result observations are contained within a Results Organizer in the Results Section. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented.

Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.

Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.

Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.

Usage:

Formal Views of Profile Content

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

This structure is derived from ResultsSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ResultsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.3.1
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1stringRequired Pattern: 30954-2
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... entry 1..*ElementIf section/@nullFlavor is not present:
... entry:organizer 1..*Element

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ResultsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.3.1
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... code 1..1stringRequired Pattern: 30954-2
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:organizer
.... entry:organizer C1..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... organizer 1..1ResultOrganizerBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType

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:organizerSHALL 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..1ResultsSectionEntriesOptionalBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.3.1
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 30954-2
.... 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 C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:organizer
.... entry:organizer C1..*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
..... organizer 1..1ResultOrganizerBase for all types and resources
... 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.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:secondary.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

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:organizerSHALL 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 ResultsSectionEntriesOptional

Summary

Mandatory: 10 elements

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from ResultsSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ResultsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.3.1
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1stringRequired Pattern: 30954-2
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... entry 1..*ElementIf section/@nullFlavor is not present:
... entry:organizer 1..*Element

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ResultsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.3.1
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... code 1..1stringRequired Pattern: 30954-2
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:organizer
.... entry:organizer C1..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... organizer 1..1ResultOrganizerBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType

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:organizerSHALL 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..1ResultsSectionEntriesOptionalBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.3.1
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 30954-2
.... 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 C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:organizer
.... entry:organizer C1..*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
..... organizer 1..1ResultOrganizerBase for all types and resources
... 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.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:secondary.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

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:organizerSHALL 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 ResultsSectionEntriesOptional

Summary

Mandatory: 10 elements

Slices

This structure defines the following Slices:

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

 

​Other representations of profile: CSV, Excel, Schematron