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: Preoperative Diagnosis (V3)

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.65 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: PreoperativeDiagnosis
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.65:2015-08-01

This template represents the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActBase for all types and resources
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.65
..... extension 1..1stringRequired Pattern: 2015-08-01
.... code 1..1stringRequired Pattern: 10219-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActBase for all types and resources
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.65
..... extension 1..1stringRequired Pattern: 2015-08-01
.... code 1..1stringRequired Pattern: 10219-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:problemObservation C1..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... contextConductionInd 1..1boolean
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Act.codeextensibleActCode

Constraints

IdGradePath(s)DetailsRequirements
act-er-1errorAct.entryRelationship, Act.entryRelationship:problemObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActBase for all types and resources
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... 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: 2.16.840.1.113883.10.20.22.4.65
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 10219-4
.... 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
.... qualifier 0..*CR
.... translation 0..*CD
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... 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
... specimen 0..*Specimen
... performer 0..*Performer2
... 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
... participant 0..*Participant2
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship: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
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (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
.... entryRelationship:problemObservation 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..1codeRequired Pattern: SUBJ
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ProblemObservationBase for all types and resources
... reference 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..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.statusCoderequiredActStatus
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
act-er-1errorAct.entryRelationship, Act.entryRelationship:problemObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
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()

This structure is derived from CDAR2.Act

Summary

Mandatory: 11 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • The element Act.entryRelationship is sliced based on the value of profile:observation

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActBase for all types and resources
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.65
..... extension 1..1stringRequired Pattern: 2015-08-01
.... code 1..1stringRequired Pattern: 10219-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:problemObservation 1..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActBase for all types and resources
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.65
..... extension 1..1stringRequired Pattern: 2015-08-01
.... code 1..1stringRequired Pattern: 10219-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:problemObservation C1..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... contextConductionInd 1..1boolean
..... observation 1..1ProblemObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Act.codeextensibleActCode

Constraints

IdGradePath(s)DetailsRequirements
act-er-1errorAct.entryRelationship, Act.entryRelationship:problemObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActBase for all types and resources
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... 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: 2.16.840.1.113883.10.20.22.4.65
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 10219-4
.... 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
.... qualifier 0..*CR
.... translation 0..*CD
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... 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
... specimen 0..*Specimen
... performer 0..*Performer2
... 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
... participant 0..*Participant2
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship: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
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (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
.... entryRelationship:problemObservation 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..1codeRequired Pattern: SUBJ
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ProblemObservationBase for all types and resources
... reference 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..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.statusCoderequiredActStatus
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
act-er-1errorAct.entryRelationship, Act.entryRelationship:problemObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
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()

This structure is derived from CDAR2.Act

Summary

Mandatory: 11 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • The element Act.entryRelationship is sliced based on the value of profile:observation

 

​Other representations of profile: CSV, Excel, Schematron