C-CDA on FHIR
1.1.0 - (FHIR R4) STU Release 1.1

This page is part of the C-CDA on FHIR Implementation Guide (v1.1.0: STU 1.1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: Care Plan Document

Defining URL:http://hl7.org/fhir/us/ccda/StructureDefinition/Care-Plan-Document
Version:1.1.0
Name:CarePlan
Title:Care Plan
Status:Active as of 2020-10-21T22:01:58+00:00
Definition:

CARE PLAN FRAMEWORK: A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient and Care Team Members prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patients care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.

A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patient's life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.

The Care Plan represents an instance of this dynamic Care Plan at a point in time. The composition itself is NOT dynamic.

Key differentiators between a Care Plan profile and CCD profile (another snapshot in time document):

  • Requires relationships between various concepts:

     *  Health Concerns
    
     *  Interventions
    
     *  Goals
    
     *  Outcomes
    
  • Provides the ability to identify patient and provider priorities with each act

  • Provides a header participant to indicate occurrences of Care Plan review

Publisher:HL7 Structured Documents Working Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/us/ccda/StructureDefinition/Care-Plan-Document

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USRealmHeader

Summary

Mandatory: 8 elements (7 nested mandatory elements)
Must-Support: 24 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.event.detail is sliced based on the value of profile:reference
  • The element Composition.section is sliced based on the value of value:code
  • The element Composition.section.entry is sliced based on the value of profile:reference

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... type S1..1CodeableConceptCare Plan Document
Binding: Care Plan Document Type (required)
... event S0..1BackboneElementThe clinical service(s) being documented
.... period S1..1PeriodThe period covered by the documentation
.... detail S0..*(Slice Definition)The event(s) being documented
Slice: Unordered, Open by profile:reference
..... detail:care_plan 0..*Reference(US Core CarePlan Profile)Care Plan Detail
... section 0..*(Slice Definition)Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:health_concerns_section S1..1BackboneElementHealth Concerns Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHealth concerns section code
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75310-3
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:health_concerns_entry S0..*Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:goals_section S1..1BackboneElementGoals Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptGoals
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 61146-7
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:goals_entry S0..*Reference(US Core Goal Profile)entry
.... section:interventions_section S0..1BackboneElementInterventions Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptInterventions provided
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 62387-6
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:interventions_section S0..*Reference(List | RequestGroup | MedicationDispense | Communication | ServiceRequest | US Core Procedure Profile | MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:eval_outcomes_section S0..1BackboneElementHealth Status Evaluations and Outcomes Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPatient problem outcome
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11383-7
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:eval_outcomes_entry S0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language S1..1codelanguage
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... composition-clinicaldocument-versionNumber 0..*stringVersion-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... VersionNumber S0..1integerExtension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
... DataEntererExtension S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
... InformantExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
... InformationRecipientExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
... ParticipantExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
... PerformerExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
... AuthorizationExtension S0..*Reference(Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
... OrderExtension S0..*Reference(ServiceRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ1..1Identifieridentifier
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptCare Plan Document
Binding: Care Plan Document Type (required)
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣ0..1Reference(US Core Patient Profile | Group)Who and/or what the composition is about
... encounter SΣ0..1Reference(US Core Encounter Profile)Context of the Composition
... date SΣ1..1dateTimedate
... author SΣ1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson)Who and/or what authored the composition
... title SΣ1..1stringDocument Title
... attester 0..*(Slice Definition)Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
..... time 0..1dateTimeWhen the composition was attested
..... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
.... attester:legal_attester S0..1BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: legal
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:professional_attester S0..*BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: professional
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:personal_attester S0..*BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: personal
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Patient Profile | RelatedPerson)party
... custodian SΣ1..1Reference(US Core Organization Profile)custodian
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event SΣ0..1BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period SΣ1..1PeriodThe period covered by the documentation
.... detail SΣ0..*(Slice Definition)The event(s) being documented
Slice: Unordered, Open by profile:reference
..... detail:care_plan Σ0..*Reference(US Core CarePlan Profile)Care Plan Detail
... section I0..*(Slice Definition)Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*Reference(Resource)A reference to data that supports this section
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section
.... section:health_concerns_section SI1..1BackboneElementHealth Concerns Section
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptHealth concerns section code
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75310-3
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:health_concerns_entry SI0..*Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section
.... section:goals_section SI1..1BackboneElementGoals Section
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptGoals
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 61146-7
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:goals_entry SI0..*Reference(US Core Goal Profile)entry
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section
.... section:interventions_section SI0..1BackboneElementInterventions Section
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptInterventions provided
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 62387-6
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:interventions_section SI0..*Reference(List | RequestGroup | MedicationDispense | Communication | ServiceRequest | US Core Procedure Profile | MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section
.... section:eval_outcomes_section SI0..1BackboneElementHealth Status Evaluations and Outcomes Section
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptPatient problem outcome
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11383-7
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:eval_outcomes_entry SI0..*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 I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... language 1..1codelanguage
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... VersionNumber 0..1integerExtension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
... DataEntererExtension 0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
... InformationRecipientExtension 0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
... ParticipantExtension 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
... PerformerExtension 0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
... AuthorizationExtension 0..*Reference(Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
... OrderExtension 0..*Reference(ServiceRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier Σ1..1Identifieridentifier
... type Σ1..1CodeableConceptCare Plan Document
Binding: Care Plan Document Type (required)
... subject Σ0..1Reference(US Core Patient Profile | Group)Who and/or what the composition is about
... encounter Σ0..1Reference(US Core Encounter Profile)Context of the Composition
... date Σ1..1dateTimedate
... author Σ1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson)Who and/or what authored the composition
... title Σ1..1stringDocument Title
... attester:legal_attester 0..1BackboneElementattester
.... mode 1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: legal
.... party 1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
... attester:professional_attester 0..*BackboneElementattester
.... mode 1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: professional
.... party 1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
... attester:personal_attester 0..*BackboneElementattester
.... mode 1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: personal
.... party 1..1Reference(US Core Patient Profile | RelatedPerson)party
... custodian Σ1..1Reference(US Core Organization Profile)custodian
... event Σ0..1BackboneElementThe clinical service(s) being documented
.... period Σ1..1PeriodThe period covered by the documentation
.... detail Σ0..*(Slice Definition)The event(s) being documented
Slice: Unordered, Open by profile:reference
... section:health_concerns_section I1..1BackboneElementHealth Concerns Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHealth concerns section code
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75310-3
.... text I1..1Narrativetext
.... entry:health_concerns_entry I0..*Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section:goals_section I1..1BackboneElementGoals Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptGoals
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 61146-7
.... text I1..1Narrativetext
.... entry:goals_entry I0..*Reference(US Core Goal Profile)entry
... section:interventions_section I0..1BackboneElementInterventions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptInterventions provided
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 62387-6
.... text I1..1Narrativetext
.... entry:interventions_section I0..*Reference(List | RequestGroup | MedicationDispense | Communication | ServiceRequest | US Core Procedure Profile | MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section:eval_outcomes_section I0..1BackboneElementHealth Status Evaluations and Outcomes Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPatient problem outcome
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11383-7
.... text I1..1Narrativetext
.... entry:eval_outcomes_entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

doco Documentation for this format

This structure is derived from USRealmHeader

Summary

Mandatory: 8 elements (7 nested mandatory elements)
Must-Support: 24 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.event.detail is sliced based on the value of profile:reference
  • The element Composition.section is sliced based on the value of value:code
  • The element Composition.section.entry is sliced based on the value of profile:reference

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... type S1..1CodeableConceptCare Plan Document
Binding: Care Plan Document Type (required)
... event S0..1BackboneElementThe clinical service(s) being documented
.... period S1..1PeriodThe period covered by the documentation
.... detail S0..*(Slice Definition)The event(s) being documented
Slice: Unordered, Open by profile:reference
..... detail:care_plan 0..*Reference(US Core CarePlan Profile)Care Plan Detail
... section 0..*(Slice Definition)Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:health_concerns_section S1..1BackboneElementHealth Concerns Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptHealth concerns section code
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75310-3
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:health_concerns_entry S0..*Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:goals_section S1..1BackboneElementGoals Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptGoals
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 61146-7
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:goals_entry S0..*Reference(US Core Goal Profile)entry
.... section:interventions_section S0..1BackboneElementInterventions Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptInterventions provided
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 62387-6
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:interventions_section S0..*Reference(List | RequestGroup | MedicationDispense | Communication | ServiceRequest | US Core Procedure Profile | MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... section:eval_outcomes_section S0..1BackboneElementHealth Status Evaluations and Outcomes Section
..... title S1..1stringtitle
..... code S1..1CodeableConceptPatient problem outcome
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11383-7
..... text S1..1Narrativetext
..... entry 0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:eval_outcomes_entry S0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*USRealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language S1..1codelanguage
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... composition-clinicaldocument-versionNumber 0..*stringVersion-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... VersionNumber S0..1integerExtension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
... DataEntererExtension S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
... InformantExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
... InformationRecipientExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
... ParticipantExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson)participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
... PerformerExtension S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
... AuthorizationExtension S0..*Reference(Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
... OrderExtension S0..*Reference(ServiceRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ1..1Identifieridentifier
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptCare Plan Document
Binding: Care Plan Document Type (required)
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣ0..1Reference(US Core Patient Profile | Group)Who and/or what the composition is about
... encounter SΣ0..1Reference(US Core Encounter Profile)Context of the Composition
... date SΣ1..1dateTimedate
... author SΣ1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson)Who and/or what authored the composition
... title SΣ1..1stringDocument Title
... attester 0..*(Slice Definition)Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
..... time 0..1dateTimeWhen the composition was attested
..... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
.... attester:legal_attester S0..1BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: legal
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:professional_attester S0..*BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: professional
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)party
.... attester:personal_attester S0..*BackboneElementattester
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... mode S1..1codemode
Binding: CompositionAttestationMode (required)
Fixed Value: personal
..... time 0..1dateTimeWhen the composition was attested
..... party S1..1Reference(US Core Patient Profile | RelatedPerson)party
... custodian SΣ1..1Reference(US Core Organization Profile)custodian
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event SΣ0..1BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period SΣ1..1PeriodThe period covered by the documentation
.... detail SΣ0..*(Slice Definition)The event(s) being documented
Slice: Unordered, Open by profile:reference
..... detail:care_plan Σ0..*Reference(US Core CarePlan Profile)Care Plan Detail
... section I0..*(Slice Definition)Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*Reference(Resource)A reference to data that supports this section
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section
.... section:health_concerns_section SI1..1BackboneElementHealth Concerns Section
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code S1..1CodeableConceptHealth concerns section code
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75310-3
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1Narrativetext
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*(Slice Definition)entry
Slice: Unordered, Open by profile:reference
...... entry:health_concerns_entry SI0..*Reference(US Core AllergyIntolerance Profile | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*See sectionNested Section
.... section:goals_section SI1..1BackboneElementGoals Section
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringtitle
..... code