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: Notes Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/NotesSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: NotesSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.65:2016-11-01

The Notes Section allow for inclusion of clinical documentation which does not fit precisely within any other C-CDA section. Multiple Notes sections may be included in a document provided they each include different types of note content as indicated by a different section.code. The Notes Section SHOULD NOT be used in place of a more specific C-CDA section. For example, notes about procedure should be placed within the Procedures Section, not a Notes Section. When a Notes Section is present, Note Activity entries contain structured information about the note information allowing it to be more machine processable.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

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)
shall-note-activity: SHALL contain at least one Note Activity
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.65
..... @extension 1..1stRequired Pattern: 2016-11-01
... code 1..1CEBinding: Note Types (preferred)
.... @code 1..1cs
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1STThis title should reflect the kind of notes included in this section, corresponding to the code.
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:note 0..*EntryIf section/@nullFlavor is not present:
..... act 1..1NoteActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.codepreferredNoteTypes

Constraints

IdGradePath(s)DetailsRequirements
shall-note-activityerrorSectionSHALL contain at least one Note Activity
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity'))
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)
shall-note-activity: SHALL contain at least one Note Activity
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.65
..... @extension 1..1stRequired Pattern: 2016-11-01
... code 1..1CEBinding: Note Types (preferred)
.... @code 1..1cs
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1STThis title should reflect the kind of notes included in this section, corresponding to the code.
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:note 0..*EntryIf section/@nullFlavor is not present:
..... act C1..1NoteActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codepreferredNoteTypes

Constraints

IdGradePath(s)DetailsRequirements
shall-note-activityerrorSectionSHALL contain at least one Note Activity
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity'))
should-text-ref-valuewarningSection.entry:note.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)
shall-note-activity: SHALL contain at least one Note Activity
... @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: 2.16.840.1.113883.10.20.22.2.65
..... @extension 1..1stRequired Pattern: 2016-11-01
... @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..1CEBinding: Note Types (preferred)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1cs
.... @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
.... translation 0..*CD
... title 1..1STThis title should reflect the kind of notes included in this section, corresponding to the code.
... text 1..1xhtmlThe narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers.&#10;&#10;While allowed by CDA, the use of <renderMultiMedia> elements, which contain a referencedObject attribute pointing to an <observationMedia> or <regionOfInterest> element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:note 0..*EntryIf section/@nullFlavor is not present:
..... @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..1NoteActivityBase 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.codepreferredNoteTypes
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:note.nullFlavorrequiredCDANullFlavor
Section.entry:note.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:note.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-note-activityerrorSectionSHALL contain at least one Note Activity
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity'))
should-text-ref-valuewarningSection.entry:note.actSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 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.entry is sliced based on the value of profile:act

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)
shall-note-activity: SHALL contain at least one Note Activity
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.65
..... @extension 1..1stRequired Pattern: 2016-11-01
... code 1..1CEBinding: Note Types (preferred)
.... @code 1..1cs
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1STThis title should reflect the kind of notes included in this section, corresponding to the code.
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:note 0..*EntryIf section/@nullFlavor is not present:
..... act 1..1NoteActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.codepreferredNoteTypes

Constraints

IdGradePath(s)DetailsRequirements
shall-note-activityerrorSectionSHALL contain at least one Note Activity
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity'))

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)
shall-note-activity: SHALL contain at least one Note Activity
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.65
..... @extension 1..1stRequired Pattern: 2016-11-01
... code 1..1CEBinding: Note Types (preferred)
.... @code 1..1cs
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1STThis title should reflect the kind of notes included in this section, corresponding to the code.
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:note 0..*EntryIf section/@nullFlavor is not present:
..... act C1..1NoteActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codepreferredNoteTypes

Constraints

IdGradePath(s)DetailsRequirements
shall-note-activityerrorSectionSHALL contain at least one Note Activity
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity'))
should-text-ref-valuewarningSection.entry:note.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)
shall-note-activity: SHALL contain at least one Note Activity
... @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: 2.16.840.1.113883.10.20.22.2.65
..... @extension 1..1stRequired Pattern: 2016-11-01
... @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..1CEBinding: Note Types (preferred)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1cs
.... @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
.... translation 0..*CD
... title 1..1STThis title should reflect the kind of notes included in this section, corresponding to the code.
... text 1..1xhtmlThe narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers.&#10;&#10;While allowed by CDA, the use of <renderMultiMedia> elements, which contain a referencedObject attribute pointing to an <observationMedia> or <regionOfInterest> element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:note 0..*EntryIf section/@nullFlavor is not present:
..... @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..1NoteActivityBase 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.codepreferredNoteTypes
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:note.nullFlavorrequiredCDANullFlavor
Section.entry:note.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:note.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-note-activityerrorSectionSHALL contain at least one Note Activity
: nullFlavor.exists() or entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity'))
should-text-ref-valuewarningSection.entry:note.actSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 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.entry is sliced based on the value of profile:act

 

Other representations of profile: CSV, Excel