C-CDA on FHIR
1.2.0-ballot - CI Build
C-CDA on FHIR
1.2.0-ballot - CI Build
This page is part of the C-CDA on FHIR Implementation Guide (v1.2.0-ballot: STU 1 Ballot 4) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Diagnostic-Imaging-Report | Version: 1.2.0-ballot | |||
| Active as of 2023-03-27 | Computable Name: DiagnosticImagingReport | |||
A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties. Note: this document type overlaps with the FHIR DiagnosticReport resource. Most use cases will want to use the specific resource type, but this document type is still useful for CDA to FHIR conversion and other such use cases.
2023 Publication of C-CDA ↔ FHIR US Core MappingThe current release of this IG adds mapping content based on a separate project from earlier publications. These mappings are intended as informative and we welcome feedback on the content added under the "Mapping" tab.
Feedback on previous publications of this implementation guide (2016-2020) outside of C-CDA ↔ FHIR mapping WILL NOT be addressed as part of ballot reconciliation although may be logged for future consideration.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  type | S | 1..1 | CodeableConcept | Diagnostic Imaging Report Binding: LOINC Imaging Document Codes (preferred) |
  Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
   section:findings_section | S | 1..1 | BackboneElement | Findings Section |
  title | S | 1..1 | string | title |
 code | S | 1..1 | CodeableConcept | Functional Status Required Pattern: At least the following |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121070 | |
| text | S | 1..1 | Narrative | text |
 Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
 entry:findings_entry | S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:dicom_object_catalog_section | S | 0..1 | BackboneElement | DICOM Object Catalog Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Dicom Object Catalog Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121181 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:dicom_object_catalog_entry | S | 0..* | Reference(ImagingStudy) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:history_section | S | 0..1 | BackboneElement | History Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121060 | |
 text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:request_section | S | 0..1 | BackboneElement | Request Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121062 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:current_procedure_descriptions_section | S | 0..1 | BackboneElement | Current Procedure Descriptions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121064 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:prior_procedure_descriptions_section | S | 0..1 | BackboneElement | Prior Procedure Descriptions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121066 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:previous_findings_section | S | 0..1 | BackboneElement | Previous Findings Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121068 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:impressions_section | S | 0..1 | BackboneElement | Impressions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121072 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:recommendations_section | S | 0..1 | BackboneElement | Impressions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121074 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
 section:conclusions_section | S | 0..1 | BackboneElement | Conclusions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121076 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.type | preferred | LOINCImagingDocumentCodes |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
| information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
| participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
| performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
 identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | Diagnostic Imaging Report Binding: LOINC Imaging Document Codes (preferred) | ||||
 subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
 Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
 attester:All Slices | Content/Rules for all slices | |||||||
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| section:findings_section | SC | 1..1 | BackboneElement | Findings Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Functional Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121070 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:findings_entry | SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| section:dicom_object_catalog_section | SC | 0..1 | BackboneElement | DICOM Object Catalog Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Dicom Object Catalog Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121181 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:dicom_object_catalog_entry | SC | 0..* | Reference(ImagingStudy) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| section:history_section | SC | 0..1 | BackboneElement | History Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121060 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:request_section | SC | 0..1 | BackboneElement | Request Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121062 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:current_procedure_descriptions_section | SC | 0..1 | BackboneElement | Current Procedure Descriptions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121064 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:prior_procedure_descriptions_section | SC | 0..1 | BackboneElement | Prior Procedure Descriptions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121066 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:previous_findings_section | SC | 0..1 | BackboneElement | Previous Findings Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121068 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:impressions_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121072 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:recommendations_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121074 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:conclusions_section | SC | 0..1 | BackboneElement | Conclusions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121076 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | LOINCImagingDocumentCodes | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legal | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professional | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personal | ||||
| Composition.section:findings_section.code | example | Pattern: 121070 | ||||
| Composition.section:dicom_object_catalog_section.code | example | Pattern: 121181 | ||||
| Composition.section:history_section.code | example | Pattern: 121060 | ||||
| Composition.section:request_section.code | example | Pattern: 121062 | ||||
| Composition.section:current_procedure_descriptions_section.code | example | Pattern: 121064 | ||||
| Composition.section:prior_procedure_descriptions_section.code | example | Pattern: 121066 | ||||
| Composition.section:previous_findings_section.code | example | Pattern: 121068 | ||||
| Composition.section:impressions_section.code | example | Pattern: 121072 | ||||
| Composition.section:recommendations_section.code | example | Pattern: 121074 | ||||
| Composition.section:conclusions_section.code | example | Pattern: 121076 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
| information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
| participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
| performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | Diagnostic Imaging Report Binding: LOINC Imaging Document Codes (preferred) | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
| Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:findings_section | SC | 1..1 | BackboneElement | Findings Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Functional Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121070 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:findings_entry | SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:dicom_object_catalog_section | SC | 0..1 | BackboneElement | DICOM Object Catalog Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Dicom Object Catalog Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121181 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:dicom_object_catalog_entry | SC | 0..* | Reference(ImagingStudy) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:history_section | SC | 0..1 | BackboneElement | History Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121060 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:request_section | SC | 0..1 | BackboneElement | Request Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121062 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:current_procedure_descriptions_section | SC | 0..1 | BackboneElement | Current Procedure Descriptions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121064 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:prior_procedure_descriptions_section | SC | 0..1 | BackboneElement | Prior Procedure Descriptions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121066 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:previous_findings_section | SC | 0..1 | BackboneElement | Previous Findings Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121068 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:impressions_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121072 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:recommendations_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121074 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:conclusions_section | SC | 0..1 | BackboneElement | Conclusions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121076 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | LOINCImagingDocumentCodes | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legal | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professional | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personal | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:findings_section.code | example | Pattern: 121070 | ||||
| Composition.section:findings_section.mode | required | ListMode | ||||
| Composition.section:findings_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:findings_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:dicom_object_catalog_section.code | example | Pattern: 121181 | ||||
| Composition.section:dicom_object_catalog_section.mode | required | ListMode | ||||
| Composition.section:dicom_object_catalog_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:dicom_object_catalog_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:history_section.code | example | Pattern: 121060 | ||||
| Composition.section:history_section.mode | required | ListMode | ||||
| Composition.section:history_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:history_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:request_section.code | example | Pattern: 121062 | ||||
| Composition.section:request_section.mode | required | ListMode | ||||
| Composition.section:request_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:request_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:current_procedure_descriptions_section.code | example | Pattern: 121064 | ||||
| Composition.section:current_procedure_descriptions_section.mode | required | ListMode | ||||
| Composition.section:current_procedure_descriptions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:current_procedure_descriptions_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:prior_procedure_descriptions_section.code | example | Pattern: 121066 | ||||
| Composition.section:prior_procedure_descriptions_section.mode | required | ListMode | ||||
| Composition.section:prior_procedure_descriptions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:prior_procedure_descriptions_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:previous_findings_section.code | example | Pattern: 121068 | ||||
| Composition.section:previous_findings_section.mode | required | ListMode | ||||
| Composition.section:previous_findings_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:previous_findings_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:impressions_section.code | example | Pattern: 121072 | ||||
| Composition.section:impressions_section.mode | required | ListMode | ||||
| Composition.section:impressions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:impressions_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:recommendations_section.code | example | Pattern: 121074 | ||||
| Composition.section:recommendations_section.mode | required | ListMode | ||||
| Composition.section:recommendations_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:recommendations_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:conclusions_section.code | example | Pattern: 121076 | ||||
| Composition.section:conclusions_section.mode | required | ListMode | ||||
| Composition.section:conclusions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:conclusions_section.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Summary
Mandatory: 4 elements (19 nested mandatory elements)
Must-Support: 43 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| type | S | 1..1 | CodeableConcept | Diagnostic Imaging Report Binding: LOINC Imaging Document Codes (preferred) |
| Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
| section:findings_section | S | 1..1 | BackboneElement | Findings Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Functional Status Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121070 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:findings_entry | S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:dicom_object_catalog_section | S | 0..1 | BackboneElement | DICOM Object Catalog Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Dicom Object Catalog Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121181 | |
| text | S | 1..1 | Narrative | text |
| Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:dicom_object_catalog_entry | S | 0..* | Reference(ImagingStudy) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:history_section | S | 0..1 | BackboneElement | History Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121060 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:request_section | S | 0..1 | BackboneElement | Request Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121062 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:current_procedure_descriptions_section | S | 0..1 | BackboneElement | Current Procedure Descriptions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121064 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:prior_procedure_descriptions_section | S | 0..1 | BackboneElement | Prior Procedure Descriptions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121066 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:previous_findings_section | S | 0..1 | BackboneElement | Previous Findings Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121068 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:impressions_section | S | 0..1 | BackboneElement | Impressions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121072 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:recommendations_section | S | 0..1 | BackboneElement | Impressions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121074 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:conclusions_section | S | 0..1 | BackboneElement | Conclusions Section |
| title | S | 0..1 | string | title |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121076 | |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.type | preferred | LOINCImagingDocumentCodes |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
| information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
| participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
| performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | Diagnostic Imaging Report Binding: LOINC Imaging Document Codes (preferred) | ||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
| Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| section:findings_section | SC | 1..1 | BackboneElement | Findings Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Functional Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121070 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:findings_entry | SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| section:dicom_object_catalog_section | SC | 0..1 | BackboneElement | DICOM Object Catalog Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Dicom Object Catalog Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121181 | |||||
| text | SC | 1..1 | Narrative | text | ||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:dicom_object_catalog_entry | SC | 0..* | Reference(ImagingStudy) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| section:history_section | SC | 0..1 | BackboneElement | History Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121060 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:request_section | SC | 0..1 | BackboneElement | Request Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121062 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:current_procedure_descriptions_section | SC | 0..1 | BackboneElement | Current Procedure Descriptions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121064 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:prior_procedure_descriptions_section | SC | 0..1 | BackboneElement | Prior Procedure Descriptions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121066 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:previous_findings_section | SC | 0..1 | BackboneElement | Previous Findings Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121068 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:impressions_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121072 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:recommendations_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121074 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| section:conclusions_section | SC | 0..1 | BackboneElement | Conclusions Section | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121076 | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | LOINCImagingDocumentCodes | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legal | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professional | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personal | ||||
| Composition.section:findings_section.code | example | Pattern: 121070 | ||||
| Composition.section:dicom_object_catalog_section.code | example | Pattern: 121181 | ||||
| Composition.section:history_section.code | example | Pattern: 121060 | ||||
| Composition.section:request_section.code | example | Pattern: 121062 | ||||
| Composition.section:current_procedure_descriptions_section.code | example | Pattern: 121064 | ||||
| Composition.section:prior_procedure_descriptions_section.code | example | Pattern: 121066 | ||||
| Composition.section:previous_findings_section.code | example | Pattern: 121068 | ||||
| Composition.section:impressions_section.code | example | Pattern: 121072 | ||||
| Composition.section:recommendations_section.code | example | Pattern: 121074 | ||||
| Composition.section:conclusions_section.code | example | Pattern: 121076 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
| data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
| informant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
| information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
| participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
| performer_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
| authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
| order_extension | S | 0..* | Reference(ServiceRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 1..1 | Identifier | identifier | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | Diagnostic Imaging Report Binding: LOINC Imaging Document Codes (preferred) | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | ||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | date | ||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title | SΣ | 1..1 | string | Document Title | ||||
| Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||
| attester:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | ||||
| attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | S | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | ||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:findings_section | SC | 1..1 | BackboneElement | Findings Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Functional Status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121070 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:findings_entry | SC | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:dicom_object_catalog_section | SC | 0..1 | BackboneElement | DICOM Object Catalog Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Dicom Object Catalog Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121181 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | text | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:dicom_object_catalog_entry | SC | 0..* | Reference(ImagingStudy) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:history_section | SC | 0..1 | BackboneElement | History Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121060 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:request_section | SC | 0..1 | BackboneElement | Request Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121062 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:current_procedure_descriptions_section | SC | 0..1 | BackboneElement | Current Procedure Descriptions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121064 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:prior_procedure_descriptions_section | SC | 0..1 | BackboneElement | Prior Procedure Descriptions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121066 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:previous_findings_section | SC | 0..1 | BackboneElement | Previous Findings Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121068 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:impressions_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121072 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:recommendations_section | SC | 0..1 | BackboneElement | Impressions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121074 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:conclusions_section | SC | 0..1 | BackboneElement | Conclusions Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 0..1 | string | title | ||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://dicom.nema.org/resources/ontology/DCM | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 121076 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | LOINCImagingDocumentCodes | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.attester:legal_attester.mode | required | Fixed Value: legal | ||||
| Composition.attester:professional_attester.mode | required | Fixed Value: professional | ||||
| Composition.attester:personal_attester.mode | required | Fixed Value: personal | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:findings_section.code | example | Pattern: 121070 | ||||
| Composition.section:findings_section.mode | required | ListMode | ||||
| Composition.section:findings_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:findings_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:dicom_object_catalog_section.code | example | Pattern: 121181 | ||||
| Composition.section:dicom_object_catalog_section.mode | required | ListMode | ||||
| Composition.section:dicom_object_catalog_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:dicom_object_catalog_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:history_section.code | example | Pattern: 121060 | ||||
| Composition.section:history_section.mode | required | ListMode | ||||
| Composition.section:history_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:history_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:request_section.code | example | Pattern: 121062 | ||||
| Composition.section:request_section.mode | required | ListMode | ||||
| Composition.section:request_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:request_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:current_procedure_descriptions_section.code | example | Pattern: 121064 | ||||
| Composition.section:current_procedure_descriptions_section.mode | required | ListMode | ||||
| Composition.section:current_procedure_descriptions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:current_procedure_descriptions_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:prior_procedure_descriptions_section.code | example | Pattern: 121066 | ||||
| Composition.section:prior_procedure_descriptions_section.mode | required | ListMode | ||||
| Composition.section:prior_procedure_descriptions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:prior_procedure_descriptions_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:previous_findings_section.code | example | Pattern: 121068 | ||||
| Composition.section:previous_findings_section.mode | required | ListMode | ||||
| Composition.section:previous_findings_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:previous_findings_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:impressions_section.code | example | Pattern: 121072 | ||||
| Composition.section:impressions_section.mode | required | ListMode | ||||
| Composition.section:impressions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:impressions_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:recommendations_section.code | example | Pattern: 121074 | ||||
| Composition.section:recommendations_section.mode | required | ListMode | ||||
| Composition.section:recommendations_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:recommendations_section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:conclusions_section.code | example | Pattern: 121076 | ||||
| Composition.section:conclusions_section.mode | required | ListMode | ||||
| Composition.section:conclusions_section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:conclusions_section.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:findings_section, Composition.section:dicom_object_catalog_section, Composition.section:history_section, Composition.section:request_section, Composition.section:current_procedure_descriptions_section, Composition.section:prior_procedure_descriptions_section, Composition.section:previous_findings_section, Composition.section:impressions_section, Composition.section:recommendations_section, Composition.section:conclusions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USRealmHeader
Summary
Mandatory: 4 elements (19 nested mandatory elements)
Must-Support: 43 elements
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 Structured Documents Working Group. Package hl7.fhir.us.ccda#1.2.0-ballot based on FHIR 4.0.1. Generated 2023-03-27
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