This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) 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/AnesthesiaSection | Version: 3.0.0-ballot | |||
Draft as of 2023-12-21 | Computable Name: AnesthesiaSection | |||
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.25:2014-06-09 |
The Anesthesia Section records the type of anesthesia (e.g., general or local) and may state the actual agent used. This may be a subsection of the Procedure Description Section. The full details of anesthesia are usually found in a separate Anesthesia Note.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.25 | |
@extension | 1..1 | st | Required Pattern: 2014-06-09 | |
code | 1..1 | CE | Anesthesia | |
@code | 1..1 | cs | Required Pattern: 59774-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:procedure, profile:substanceAdministration | |
entry:procedure | 0..* | Entry | ||
procedure | 1..1 | ProcedureActivityProcedure | Base for all types and resources | |
entry:medication | 0..* | Entry | ||
substanceAdministration | 1..1 | MedicationActivity | Base for all types and resources | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.25 | |
@extension | 1..1 | st | Required Pattern: 2014-06-09 | |
code | 1..1 | CE | Anesthesia Binding: DocumentSectionType (example) | |
@code | 1..1 | cs | Required Pattern: 59774-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:procedure, profile:substanceAdministration | |
entry:procedure | 0..* | Entry | ||
procedure | C | 1..1 | ProcedureActivityProcedure | Base for all types and resources |
entry:medication | 0..* | Entry | ||
substanceAdministration | C | 1..1 | MedicationActivity | Base for all types and resources |
Documentation for this format |
Path | Conformance | ValueSet |
Section.code | example | DocumentSectionType |
Id | Grade | Path(s) | Details | Requirements |
1098-7513 | warning | Section.entry:medication.substanceAdministration | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
active-high-ts-after-document | error | Section.entry:procedure.procedure | If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime : (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value | |
dose-unit-or-admin-unit | error | Section.entry:medication.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
should-author | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain author : author.exists() | |
should-performer | warning | Section.entry:procedure.procedure | SHOULD contain performer : performer.exists() | |
should-routeCode | warning | Section.entry:medication.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
should-targetSiteCode | warning | Section.entry:procedure.procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
should-text-ref-value | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() |
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | CDANullFlavor |
Section.typeId.nullFlavor | required | CDANullFlavor |
Section.templateId:section.nullFlavor | required | CDANullFlavor |
Section.classCode | required | Fixed Value: DOCSECT |
Section.moodCode | required | Fixed Value: EVN |
Section.code | example | DocumentSectionType |
Section.code.nullFlavor | required | CDANullFlavor |
Section.languageCode | required | AllLanguages |
Section.entry:procedure.nullFlavor | required | CDANullFlavor |
Section.entry:procedure.typeId.nullFlavor | required | CDANullFlavor |
Section.entry:procedure.typeCode | required | XActRelationshipEntry |
Section.entry:medication.nullFlavor | required | CDANullFlavor |
Section.entry:medication.typeId.nullFlavor | required | CDANullFlavor |
Section.entry:medication.typeCode | required | XActRelationshipEntry |
Section.component.nullFlavor | required | CDANullFlavor |
Section.component.typeId.nullFlavor | required | CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
1098-7513 | warning | Section.entry:medication.substanceAdministration | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
active-high-ts-after-document | error | Section.entry:procedure.procedure | If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime : (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value | |
dose-unit-or-admin-unit | error | Section.entry:medication.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
should-author | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain author : author.exists() | |
should-performer | warning | Section.entry:procedure.procedure | SHOULD contain performer : performer.exists() | |
should-routeCode | warning | Section.entry:medication.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
should-targetSiteCode | warning | Section.entry:procedure.procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
should-text-ref-value | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() |
This structure is derived from Section
Summary
Mandatory: 9 elements (2 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 Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.25 | |
@extension | 1..1 | st | Required Pattern: 2014-06-09 | |
code | 1..1 | CE | Anesthesia | |
@code | 1..1 | cs | Required Pattern: 59774-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:procedure, profile:substanceAdministration | |
entry:procedure | 0..* | Entry | ||
procedure | 1..1 | ProcedureActivityProcedure | Base for all types and resources | |
entry:medication | 0..* | Entry | ||
substanceAdministration | 1..1 | MedicationActivity | Base for all types and resources | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.25 | |
@extension | 1..1 | st | Required Pattern: 2014-06-09 | |
code | 1..1 | CE | Anesthesia Binding: DocumentSectionType (example) | |
@code | 1..1 | cs | Required Pattern: 59774-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:procedure, profile:substanceAdministration | |
entry:procedure | 0..* | Entry | ||
procedure | C | 1..1 | ProcedureActivityProcedure | Base for all types and resources |
entry:medication | 0..* | Entry | ||
substanceAdministration | C | 1..1 | MedicationActivity | Base for all types and resources |
Documentation for this format |
Path | Conformance | ValueSet |
Section.code | example | DocumentSectionType |
Id | Grade | Path(s) | Details | Requirements |
1098-7513 | warning | Section.entry:medication.substanceAdministration | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
active-high-ts-after-document | error | Section.entry:procedure.procedure | If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime : (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value | |
dose-unit-or-admin-unit | error | Section.entry:medication.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
should-author | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain author : author.exists() | |
should-performer | warning | Section.entry:procedure.procedure | SHOULD contain performer : performer.exists() | |
should-routeCode | warning | Section.entry:medication.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
should-targetSiteCode | warning | Section.entry:procedure.procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
should-text-ref-value | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() |
Snapshot View
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | CDANullFlavor |
Section.typeId.nullFlavor | required | CDANullFlavor |
Section.templateId:section.nullFlavor | required | CDANullFlavor |
Section.classCode | required | Fixed Value: DOCSECT |
Section.moodCode | required | Fixed Value: EVN |
Section.code | example | DocumentSectionType |
Section.code.nullFlavor | required | CDANullFlavor |
Section.languageCode | required | AllLanguages |
Section.entry:procedure.nullFlavor | required | CDANullFlavor |
Section.entry:procedure.typeId.nullFlavor | required | CDANullFlavor |
Section.entry:procedure.typeCode | required | XActRelationshipEntry |
Section.entry:medication.nullFlavor | required | CDANullFlavor |
Section.entry:medication.typeId.nullFlavor | required | CDANullFlavor |
Section.entry:medication.typeCode | required | XActRelationshipEntry |
Section.component.nullFlavor | required | CDANullFlavor |
Section.component.typeId.nullFlavor | required | CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
1098-7513 | warning | Section.entry:medication.substanceAdministration | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
active-high-ts-after-document | error | Section.entry:procedure.procedure | If the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime : (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value | |
dose-unit-or-admin-unit | error | Section.entry:medication.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
should-author | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain author : author.exists() | |
should-performer | warning | Section.entry:procedure.procedure | SHOULD contain performer : performer.exists() | |
should-routeCode | warning | Section.entry:medication.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
should-targetSiteCode | warning | Section.entry:procedure.procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
should-text-ref-value | warning | Section.entry:procedure.procedure, Section.entry:medication.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() |
This structure is derived from Section
Summary
Mandatory: 9 elements (2 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: