Consolidated CDA
3.0.0-ballot - ballot
Consolidated CDA
3.0.0-ballot - ballot
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/EncounterDiagnosis | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | 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. The Problem Status template in the Problem Observation entry indicates the status of the diagnosis.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:encounter-dx | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
  @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
 @classCode | 1..1 | cs | Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| code | 1..1 | CD | Diagnosis | |
| @code | 1..1 | cs | Required Pattern: 29308-4 | |
 @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | Fixed Value: completed | |
 Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
 observation | 1..1 | ProblemObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:encounter-dx | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| @classCode | 1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| code | 1..1 | CD | Diagnosis Binding: v3 Code System ActCode (example) | |
| @code | 1..1 | cs | Required Pattern: 29308-4 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| observation | C | 1..1 | ProblemObservation | Base for all types and resources |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.statusCode | required | ActStatus |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Path | Conformance | ValueSet / Code |
| Act.nullFlavor | required | CDANullFlavor |
| Act.typeId.nullFlavor | required | CDANullFlavor |
| Act.templateId:encounter-dx.nullFlavor | required | CDANullFlavor |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.code.nullFlavor | required | CDANullFlavor |
| Act.text.nullFlavor | required | CDANullFlavor |
| Act.text.compression | required | CDACompressionAlgorithm |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Act.text.mediaType | example | MediaType |
| Act.text.representation | required | BinaryDataEncoding |
| Act.statusCode | required | ActStatus |
| Act.statusCode.nullFlavor | required | CDANullFlavor |
| Act.priorityCode | example | ActPriority |
| Act.languageCode | required | AllLanguages |
| Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 11 elements
Fixed Value: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:encounter-dx | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| @classCode | 1..1 | cs | Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| code | 1..1 | CD | Diagnosis | |
| @code | 1..1 | cs | Required Pattern: 29308-4 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:encounter-dx | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.80 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| @classCode | 1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| code | 1..1 | CD | Diagnosis Binding: v3 Code System ActCode (example) | |
| @code | 1..1 | cs | Required Pattern: 29308-4 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| observation | C | 1..1 | ProblemObservation | Base for all types and resources |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.statusCode | required | ActStatus |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Path | Conformance | ValueSet / Code |
| Act.nullFlavor | required | CDANullFlavor |
| Act.typeId.nullFlavor | required | CDANullFlavor |
| Act.templateId:encounter-dx.nullFlavor | required | CDANullFlavor |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.code.nullFlavor | required | CDANullFlavor |
| Act.text.nullFlavor | required | CDANullFlavor |
| Act.text.compression | required | CDACompressionAlgorithm |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Act.text.mediaType | example | MediaType |
| Act.text.representation | required | BinaryDataEncoding |
| Act.statusCode | required | ActStatus |
| Act.statusCode.nullFlavor | required | CDANullFlavor |
| Act.priorityCode | example | ActPriority |
| Act.languageCode | required | AllLanguages |
| Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 11 elements
Fixed Value: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-21
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