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: Medical (General) History Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.39 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: MedicalGeneralHistorySection
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.2.39

The Medical History Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.

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
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.39
... code 1..1CE
.... code 1..1stringRequired Pattern: 11329-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED

doco Documentation for this format
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
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.39
.... code 1..1stringRequired Pattern: 11329-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... 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

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
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
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.39
..... extension 0..1string
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 11329-0
.... 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
... 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

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.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: 7 elements

Slices

This structure defines the following Slices:

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

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
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.39
... code 1..1CE
.... code 1..1stringRequired Pattern: 11329-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED

doco Documentation for this format

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
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.39
.... code 1..1stringRequired Pattern: 11329-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... 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

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

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
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.39
..... extension 0..1string
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 11329-0
.... 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
... 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

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.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: 7 elements

Slices

This structure defines the following Slices:

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

 

​Other representations of profile: CSV, Excel, Schematron