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) generated with FHIR (HL7® FHIR® Standard) v5.0.0. The current version which supersedes this version is 4.0.0. For a full list of available versions, see the Directory of published versions

Logical Model: Preoperative Diagnosis Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: PreoperativeDiagnosisSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.34:2015-08-01

The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon’s opinion, the diagnosis that will be confirmed during surgery.

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-preop-dx: SHOULD contain Preoperative Diagnosis
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.34
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPreoperative Diagnosis
.... @code 1..1csRequired Pattern: 10219-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:preopDiagnosis 0..1Entry
..... act 1..1PreoperativeDiagnosisBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-preop-dxwarningSectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
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-preop-dx: SHOULD contain Preoperative Diagnosis
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.34
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPreoperative Diagnosis
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 10219-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:preopDiagnosis 0..1Entry
..... act C1..1PreoperativeDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-preop-dxwarningSectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-text-ref-valuewarningSection.entry:preopDiagnosis.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-preop-dx: SHOULD contain Preoperative Diagnosis
... @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: 2.16.840.1.113883.10.20.22.2.34
..... @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..1CEPreoperative Diagnosis
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 10219-4
.... @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..1ST
... text 1..1xhtml
... 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:preopDiagnosis 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..1PreoperativeDiagnosisBase 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.languageCoderequiredAllLanguages
Section.entry:preopDiagnosis.nullFlavorrequiredCDANullFlavor
Section.entry:preopDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:preopDiagnosis.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-preop-dxwarningSectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-text-ref-valuewarningSection.entry:preopDiagnosis.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)
should-preop-dx: SHOULD contain Preoperative Diagnosis
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.34
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPreoperative Diagnosis
.... @code 1..1csRequired Pattern: 10219-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:preopDiagnosis 0..1Entry
..... act 1..1PreoperativeDiagnosisBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-preop-dxwarningSectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))

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-preop-dx: SHOULD contain Preoperative Diagnosis
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.34
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPreoperative Diagnosis
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 10219-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:act
.... entry:preopDiagnosis 0..1Entry
..... act C1..1PreoperativeDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-preop-dxwarningSectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-text-ref-valuewarningSection.entry:preopDiagnosis.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-preop-dx: SHOULD contain Preoperative Diagnosis
... @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: 2.16.840.1.113883.10.20.22.2.34
..... @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..1CEPreoperative Diagnosis
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 10219-4
.... @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..1ST
... text 1..1xhtml
... 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:preopDiagnosis 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..1PreoperativeDiagnosisBase 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.languageCoderequiredAllLanguages
Section.entry:preopDiagnosis.nullFlavorrequiredCDANullFlavor
Section.entry:preopDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:preopDiagnosis.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-preop-dxwarningSectionSHOULD contain Preoperative Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))
should-text-ref-valuewarningSection.entry:preopDiagnosis.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