This page is part of the CCDA: Consolidated CDA Release (v4.0.0-ballot: CCDA 4.0 Ballot) 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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection | Version: 4.0.0-ballot | |||
| Draft as of 2024-12-20 | Computable Name: AssessmentSection | |||
| Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.8 | ||||
The Assessment Section (also referred to as "impression" or "diagnoses" outside of the context of CDA) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment may be a list of specific disease entities or a narrative block.
Wrapping the text of this section in a Note Activity will support ingestion.
Usage:
Description of Template, 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
|    Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
|     templateId:section | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.8 | |
|      @extension | 0..0 | |||
|    code | 1..1 | CE | Evaluation note | |
|     @code | 1..1 | cs | Required Pattern: 51848-0 | |
|     @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:act | |
|     entry:notes | 0..* | Entry | ||
|      act | 1..1 | NoteActivity | ||
|  Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI | 
| Section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:notes.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | 
| Id | Grade | Path(s) | Details | Requirements | 
| II-1 | error | Section.typeId, Section.entry:notes.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | 
| Path | Conformance | ValueSet / Code | URI | 
| Section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:notes.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | 
| Id | Grade | Path(s) | Details | Requirements | 
| II-1 | error | Section.typeId, Section.entry:notes.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | 
This structure is derived from Section
Summary
Mandatory: 8 elements(1 nested mandatory element)
 Prohibited: 1 element
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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
|    Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
|     templateId:section | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.8 | |
|      @extension | 0..0 | |||
|    code | 1..1 | CE | Evaluation note | |
|     @code | 1..1 | cs | Required Pattern: 51848-0 | |
|     @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:act | |
|     entry:notes | 0..* | Entry | ||
|      act | 1..1 | NoteActivity | ||
|  Documentation for this format | ||||
Key Elements View
| Path | Conformance | ValueSet / Code | URI | 
| Section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:notes.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | 
| Id | Grade | Path(s) | Details | Requirements | 
| II-1 | error | Section.typeId, Section.entry:notes.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | 
Snapshot View
| Path | Conformance | ValueSet / Code | URI | 
| Section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:notes.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:notes.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | 
| Id | Grade | Path(s) | Details | Requirements | 
| II-1 | error | Section.typeId, Section.entry:notes.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | 
This structure is derived from Section
Summary
Mandatory: 8 elements(1 nested mandatory element)
 Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: