This page is part of the CCDA: Consolidated CDA Release (v4.0.0: CCDA 4.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection | Version: 4.0.0 | |||
| Draft as of 2025-06-20 | Computable Name: SocialHistorySection | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2015-08-01 | ||||
This section contains social history data that influence a patient's physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header. Mental/behavioral health assessments such as PHQ-9 (Patient Health Questionnaire-9) for depression screening are captured in the Mental Status section.
Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:
Recommended Entries: SmokingStatus
Optional Entries: CaregiverCharacteristics, CharacteristicsofHomeEnvironment, CulturalandReligiousObservation, PregnancyIntentionInNextYear, PregnancyStatusObservation, SocialHistoryObservation
Usages:
Changes since version 3.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Id | Grade | Path(s) | Details | Requirements | 
| should-smoking-status | warning | Section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | 
| 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:socialHistory.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyPregnancy.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:smokingStatus.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:caregiver.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:culturalReligious.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:homeCharacteristics.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyIntention.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.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:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-smoking-status | warning | Section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | 
| 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:socialHistory.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyPregnancy.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:smokingStatus.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:caregiver.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:culturalReligious.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:homeCharacteristics.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyIntention.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.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:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-smoking-status | warning | Section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | 
This structure is derived from Section
Summary
Mandatory: 9 elements(7 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Section
| Id | Grade | Path(s) | Details | Requirements | 
| should-smoking-status | warning | Section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | 
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:socialHistory.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyPregnancy.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:smokingStatus.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:caregiver.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:culturalReligious.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:homeCharacteristics.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyIntention.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.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:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-smoking-status | warning | Section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | 
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:socialHistory.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:socialHistory.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyPregnancy.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyPregnancy.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:smokingStatus.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:smokingStatus.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:caregiver.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:caregiver.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:culturalReligious.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:culturalReligious.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:homeCharacteristics.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:homeCharacteristics.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:pregnancyIntention.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:pregnancyIntention.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:socialHistory.typeId, Section.entry:pregnancyPregnancy.typeId, Section.entry:smokingStatus.typeId, Section.entry:caregiver.typeId, Section.entry:culturalReligious.typeId, Section.entry:homeCharacteristics.typeId, Section.entry:pregnancyIntention.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-smoking-status | warning | Section | SHOULD contain Smoking Status : entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus')) | 
This structure is derived from Section
Summary
Mandatory: 9 elements(7 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: