Consolidated CDA
3.0.0-ballot - ballot United States of America flag

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

Logical Model: Discharge Diagnosis Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/DischargeDiagnosisSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: DischargeDiagnosisSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.24:2015-08-01

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization. This section includes an optional entry to record patient diagnoses specific to this visit. Problems that need ongoing tracking should also be included in the Problem Section.

Usage:

Formal Views of Profile Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML 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)
should-entry: SHOULD contain entry
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEHospital Discharge Diagnosis
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CDDischarge Diagnosis
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-entrywarningSectionSHOULD contain entry
: entry.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML 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)
should-entry: SHOULD contain entry
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEHospital Discharge Diagnosis
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CDDischarge Diagnosis
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act C1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-entrywarningSectionSHOULD contain entry
: entry.exists()
should-text-ref-valuewarningSection.entry.actSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML 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)
should-entry: SHOULD contain entry
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEHospital Discharge Diagnosis
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CDDischarge Diagnosis
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... qualifier 0..*CR
...... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... entry 0..1Entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
.... @contextConductionInd 0..1blFixed Value: true
.... act C1..1HospitalDischargeDiagnosisBase for all types and resources
.... encounter 0..1Encounter
.... observation 0..1Observation
.... observationMedia 0..1ObservationMedia
.... organizer 0..1Organizer
.... procedure 0..1Procedure
.... regionOfInterest 0..1RegionOfInterest
.... substanceAdministration 0..1SubstanceAdministration
.... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.code.translation:translation1.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry.nullFlavorrequiredCDANullFlavor
Section.entry.typeId.nullFlavorrequiredCDANullFlavor
Section.entry.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-entrywarningSectionSHOULD contain entry
: entry.exists()
should-text-ref-valuewarningSection.entry.actSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 13 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML 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)
should-entry: SHOULD contain entry
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEHospital Discharge Diagnosis
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CDDischarge Diagnosis
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act 1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-entrywarningSectionSHOULD contain entry
: entry.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML 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)
should-entry: SHOULD contain entry
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEHospital Discharge Diagnosis
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CDDischarge Diagnosis
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... entry 0..1Entry
.... act C1..1HospitalDischargeDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-entrywarningSectionSHOULD contain entry
: entry.exists()
should-text-ref-valuewarningSection.entry.actSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML 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)
should-entry: SHOULD contain entry
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.24
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEHospital Discharge Diagnosis
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 11535-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... Slices for translation 1..*CDSlice: Unordered, Open by value:code, value:codeSystem
..... translation:translation1 1..1CDDischarge Diagnosis
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @code 1..1csRequired Pattern: 78375-3
...... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... qualifier 0..*CR
...... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... entry 0..1Entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
.... @contextConductionInd 0..1blFixed Value: true
.... act C1..1HospitalDischargeDiagnosisBase for all types and resources
.... encounter 0..1Encounter
.... observation 0..1Observation
.... observationMedia 0..1ObservationMedia
.... organizer 0..1Organizer
.... procedure 0..1Procedure
.... regionOfInterest 0..1RegionOfInterest
.... substanceAdministration 0..1SubstanceAdministration
.... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.code.translation:translation1.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry.nullFlavorrequiredCDANullFlavor
Section.entry.typeId.nullFlavorrequiredCDANullFlavor
Section.entry.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-entrywarningSectionSHOULD contain entry
: entry.exists()
should-text-ref-valuewarningSection.entry.actSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 13 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel