This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) generated with 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/2.16.840.1.113883.10.20.22.4.80 | Version: 2.1.0-draft1 | |||
Active as of 2023-01-16 | Computable Name: EncounterDiagnosis | |||
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2015-08-01 |
This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Act
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Act | 1..1 | CDAR2.Act | Base for all types and resources | |
classCode | 1..1 | code | Required Pattern: ACT | |
moodCode | 1..1 | code | Required Pattern: EVN | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: 29308-4 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
entryRelationship:problemObservation | 1..* | Element | ||
typeCode | 1..1 | code | Required Pattern: SUBJ | |
observation | 1..1 | ProblemObservation | Base for all types and resources | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Act | 1..1 | CDAR2.Act | Base for all types and resources | |
classCode | 1..1 | code | Required Pattern: ACT | |
moodCode | 1..1 | code | Required Pattern: EVN | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CD | Binding: v3 Code System ActCode (extensible) | |
code | 1..1 | string | Required Pattern: 29308-4 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
entryRelationship:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | ||
contextConductionInd | 1..1 | boolean | ||
entryRelationship:problemObservation | C | 1..* | Element | |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
contextConductionInd | 1..1 | boolean | ||
observation | 1..1 | ProblemObservation | Base for all types and resources | |
Documentation for this format |
Path | Conformance | ValueSet |
Act.code | extensible | ActCode |
Id | Grade | Path(s) | Details | Requirements |
act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Path | Conformance | ValueSet / Code |
Act.templateId:primary.nullFlavor | required | NullFlavor |
Act.code | extensible | ActCode |
Act.code.nullFlavor | required | NullFlavor |
Act.statusCode | required | ActStatus |
Act.priorityCode | extensible | ActPriority |
Act.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Act.subject.typeCode | required | Fixed Value: SBJ |
Act.subject.contextControlCode | required | Fixed Value: OP |
Act.subject.awarenessCode | extensible | TargetAwareness |
Act.informant.typeCode | required | Fixed Value: INF |
Act.informant.contextControlCode | required | Fixed Value: OP |
Id | Grade | Path(s) | Details | Requirements |
act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
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() |
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:
Differential View
This structure is derived from CDAR2.Act
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Act | 1..1 | CDAR2.Act | Base for all types and resources | |
classCode | 1..1 | code | Required Pattern: ACT | |
moodCode | 1..1 | code | Required Pattern: EVN | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: 29308-4 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
entryRelationship:problemObservation | 1..* | Element | ||
typeCode | 1..1 | code | Required Pattern: SUBJ | |
observation | 1..1 | ProblemObservation | Base for all types and resources | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Act | 1..1 | CDAR2.Act | Base for all types and resources | |
classCode | 1..1 | code | Required Pattern: ACT | |
moodCode | 1..1 | code | Required Pattern: EVN | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CD | Binding: v3 Code System ActCode (extensible) | |
code | 1..1 | string | Required Pattern: 29308-4 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
entryRelationship:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | ||
contextConductionInd | 1..1 | boolean | ||
entryRelationship:problemObservation | C | 1..* | Element | |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
contextConductionInd | 1..1 | boolean | ||
observation | 1..1 | ProblemObservation | Base for all types and resources | |
Documentation for this format |
Path | Conformance | ValueSet |
Act.code | extensible | ActCode |
Id | Grade | Path(s) | Details | Requirements |
act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
Path | Conformance | ValueSet / Code |
Act.templateId:primary.nullFlavor | required | NullFlavor |
Act.code | extensible | ActCode |
Act.code.nullFlavor | required | NullFlavor |
Act.statusCode | required | ActStatus |
Act.priorityCode | extensible | ActPriority |
Act.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Act.subject.typeCode | required | Fixed Value: SBJ |
Act.subject.contextControlCode | required | Fixed Value: OP |
Act.subject.awarenessCode | extensible | TargetAwareness |
Act.informant.typeCode | required | Fixed Value: INF |
Act.informant.contextControlCode | required | Fixed Value: OP |
Id | Grade | Path(s) | Details | Requirements |
act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
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() |
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:
Other representations of profile: CSV, Excel, Schematron