C-CDA on FHIR
1.1.0 - (FHIR R4) STU Release 1.1
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 
| Defining URL: | http://hl7.org/fhir/us/ccda/StructureDefinition/Progress-Note |
| Version: | 1.1.0 |
| Name: | ProgressNote |
| Title: | Progress Note |
| Status: | Active as of 2020-10-21T22:01:58+00:00 |
| Definition: | This profile represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. Taber's medical dictionary defines a Progress Note as An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. Mosby's medical dictionary defines a Progress Note as Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned. A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report. |
| 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/Progress-Note
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Summary
Mandatory: 0 element (48 nested mandatory elements)
Must-Support: 75 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
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 | type Binding: ProgressNoteDocumentTypeCode (required) |
  section | 0..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open by value:code | |
   section:assessment_section | S | 0..1 | BackboneElement | Assessment Section |
  title | S | 1..1 | string | title |
 code | S | 1..1 | CodeableConcept | Assessments 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://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
 text | S | 1..1 | Narrative | This section contains only human readable content |
| section:allergies_and_intolerances_section | S | 0..1 | BackboneElement | Allergies and Intolerances Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text | 1..1 | Narrative | text | |
 entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
 entry:allergies_and_intolerances_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:assessment_and_plan_section | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessment and plan 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:assessment_and_plan_entry | S | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Chief complaint 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:instructions_section | S | 0..1 | BackboneElement | Instructions Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Instructions 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:interventions_section | S | 0..1 | BackboneElement | Interventions Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Interventions provided 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 62387-6 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:interventions_section | S | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:medications_section | S | 0..1 | BackboneElement | Medications Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of medication use 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:medications_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| section:nutrition_section | S | 0..1 | BackboneElement | Nutrition Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Diet and nutrition 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
| text | S | 1..1 | Narrative | text |
| entry | S | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:nutrition_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:objective_section | S | 0..1 | BackboneElement | Objective Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Objective 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:physical_exam_section | S | 0..1 | BackboneElement | Physical Exam Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Physical findings 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:physical_exam_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:plan_of_treatment_section | S | 0..1 | BackboneElement | Plan of Treatment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Plan of Treatment 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:sliceEntry | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
| section:problems_section | S | 0..1 | BackboneElement | Problems Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Problem list 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:problem_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:results_section | S | 0..1 | BackboneElement | Results Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | S | 1..1 | Narrative | text |
| entry | S | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:results_entry | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| section:review_of_systems_section | S | 0..1 | BackboneElement | Review of Systems Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Review of systems 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:subjective_section | S | 0..1 | BackboneElement | Subjective Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Subjective 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61150-9 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
 section:vital_signs_section | S | 0..1 | BackboneElement | Vital Signs Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Vital signs 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:vital_signs_entry | S | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| Documentation for this format | ||||
| 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 | string | 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) Max Binding: AllLanguages |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| VersionNumber | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber |
| DataEntererExtension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension |
| InformantExtension | 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 |
| InformationRecipientExtension | 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 |
| ParticipantExtension | 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 |
| PerformerExtension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension |
| AuthorizationExtension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension |
| OrderExtension | 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) |
| type | SΣ | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example) |
 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 |
 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..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) | |
| 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) 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) 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) 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) | |
 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) |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 0..* | (Slice Definition) | 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) | |
| 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 | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:assessment_section | SI | 0..1 | BackboneElement | Assessment 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 | Assessments Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:allergies_and_intolerances_section | SI | 0..1 | BackboneElement | Allergies and Intolerances 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 | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| 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 | I | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:allergies_and_intolerances_entry | SI | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:assessment_and_plan_section | SI | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
| 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 | Assessment and plan Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:assessment_and_plan_entry | SI | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:chief_complaint_section | SI | 0..1 | BackboneElement | Chief Complaint 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 | Chief complaint Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:instructions_section | SI | 0..1 | BackboneElement | Instructions 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 | Instructions Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:interventions_section | SI | 0..1 | BackboneElement | Interventions 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 | Interventions provided Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 62387-6 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:interventions_section | SI | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:medications_section | SI | 0..1 | BackboneElement | Medications 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 | History of medication use Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:medications_entry | SI | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:nutrition_section | SI | 0..1 | BackboneElement | Nutrition 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 | Diet and nutrition Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | SI | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:nutrition_entry | SI | 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 | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:objective_section | SI | 0..1 | BackboneElement | Objective 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 | Objective Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:physical_exam_section | SI | 0..1 | BackboneElement | Physical Exam 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 | Physical findings Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:physical_exam_entry | SI | 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 | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:plan_of_treatment_section | SI | 0..1 | BackboneElement | Plan of Treatment 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 | Plan of Treatment Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:sliceEntry | I | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:problems_section | SI | 0..1 | BackboneElement | Problems 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 | Problem list Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:problem_entry | SI | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:results_section | SI | 0..1 | BackboneElement | Results 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 | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | SI | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:results_entry | SI | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:review_of_systems_section | SI | 0..1 | BackboneElement | Review of Systems 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 | Review of systems Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:subjective_section | SI | 0..1 | BackboneElement | Subjective 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 | Subjective Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61150-9 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:vital_signs_section | SI | 0..1 | BackboneElement | Vital Signs 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 | Vital signs Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:vital_signs_entry | SI | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| language | 1..1 | code | language Binding: CommonLanguages (preferred) Max Binding: AllLanguages | |
| VersionNumber | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | |
| DataEntererExtension | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | |
| InformantExtension | 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 | |
| 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 | Σ | 1..1 | Identifier | identifier |
| type | Σ | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) |
| subject | Σ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about |
| encounter | Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition |
| date | Σ | 1..1 | dateTime | date |
| author | Σ | 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 | Σ | 1..1 | string | Document Title |
| attester:legal_attester | 0..1 | BackboneElement | attester | |
| mode | 1..1 | code | mode Binding: CompositionAttestationMode (required) Fixed Value: legal | |
| party | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | |
| attester:professional_attester | 0..* | BackboneElement | attester | |
| mode | 1..1 | code | mode Binding: CompositionAttestationMode (required) Fixed Value: professional | |
| party | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | party | |
| attester:personal_attester | 0..* | BackboneElement | attester | |
| mode | 1..1 | code | mode Binding: CompositionAttestationMode (required) Fixed Value: personal | |
| party | 1..1 | Reference(US Core Patient Profile | RelatedPerson) | party | |
| custodian | Σ | 1..1 | Reference(US Core Organization Profile) | custodian |
| section:assessment_section | I | 0..1 | BackboneElement | Assessment Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Assessments Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
| text | I | 1..1 | Narrative | This section contains only human readable content |
| section:allergies_and_intolerances_section | I | 0..1 | BackboneElement | Allergies and Intolerances Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| entry:allergies_and_intolerances_entry | I | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:assessment_and_plan_section | I | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Assessment and plan Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| text | I | 1..1 | Narrative | text |
| entry:assessment_and_plan_entry | I | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:chief_complaint_section | I | 0..1 | BackboneElement | Chief Complaint Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Chief complaint Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| text | I | 1..1 | Narrative | This section contains only human readable content |
| section:instructions_section | I | 0..1 | BackboneElement | Instructions Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Instructions Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| text | I | 1..1 | Narrative | This section contains only human readable content |
| section:interventions_section | I | 0..1 | BackboneElement | Interventions Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Interventions provided Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 62387-6 | |
| text | I | 1..1 | Narrative | text |
| entry:interventions_section | I | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:medications_section | I | 0..1 | BackboneElement | Medications Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | I | 1..1 | Narrative | text |
| entry:medications_entry | I | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| section:nutrition_section | I | 0..1 | BackboneElement | Nutrition Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
| text | I | 1..1 | Narrative | text |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:nutrition_entry | I | 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:objective_section | I | 0..1 | BackboneElement | Objective Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Objective Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | |
| text | I | 1..1 | Narrative | This section contains only human readable content |
| section:physical_exam_section | I | 0..1 | BackboneElement | Physical Exam Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Physical findings Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| text | I | 1..1 | Narrative | text |
| entry:physical_exam_entry | I | 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:plan_of_treatment_section | I | 0..1 | BackboneElement | Plan of Treatment Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Plan of Treatment Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | I | 1..1 | Narrative | text |
| section:problems_section | I | 0..1 | BackboneElement | Problems Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | I | 1..1 | Narrative | text |
| entry:problem_entry | I | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:results_section | I | 0..1 | BackboneElement | Results Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | I | 1..1 | Narrative | text |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:results_entry | I | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| section:review_of_systems_section | I | 0..1 | BackboneElement | Review of Systems Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Review of systems Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| text | I | 1..1 | Narrative | This section contains only human readable content |
| section:subjective_section | I | 0..1 | BackboneElement | Subjective Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Subjective Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61150-9 | |
| text | I | 1..1 | Narrative | This section contains only human readable content |
| section:vital_signs_section | I | 0..1 | BackboneElement | Vital Signs Section |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| text | I | 1..1 | Narrative | text |
| entry:vital_signs_entry | I | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| Documentation for this format | ||||
This structure is derived from USRealmHeader
Summary
Mandatory: 0 element (48 nested mandatory elements)
Must-Support: 75 elements
Structures
This structure refers to these other structures:
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 | type Binding: ProgressNoteDocumentTypeCode (required) |
| section | 0..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open by value:code | |
| section:assessment_section | S | 0..1 | BackboneElement | Assessment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessments 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:allergies_and_intolerances_section | S | 0..1 | BackboneElement | Allergies and Intolerances Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:allergies_and_intolerances_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| section:assessment_and_plan_section | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Assessment and plan 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:assessment_and_plan_entry | S | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Chief complaint 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:instructions_section | S | 0..1 | BackboneElement | Instructions Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Instructions 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:interventions_section | S | 0..1 | BackboneElement | Interventions Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Interventions provided 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 62387-6 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:interventions_section | S | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| section:medications_section | S | 0..1 | BackboneElement | Medications Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | History of medication use 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:medications_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| section:nutrition_section | S | 0..1 | BackboneElement | Nutrition Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Diet and nutrition 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
| text | S | 1..1 | Narrative | text |
| entry | S | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:nutrition_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:objective_section | S | 0..1 | BackboneElement | Objective Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Objective 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:physical_exam_section | S | 0..1 | BackboneElement | Physical Exam Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Physical findings 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:physical_exam_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:plan_of_treatment_section | S | 0..1 | BackboneElement | Plan of Treatment Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Plan of Treatment 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:sliceEntry | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
| section:problems_section | S | 0..1 | BackboneElement | Problems Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Problem list 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:problem_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| section:results_section | S | 0..1 | BackboneElement | Results Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | S | 1..1 | Narrative | text |
| entry | S | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:results_entry | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| section:review_of_systems_section | S | 0..1 | BackboneElement | Review of Systems Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Review of systems 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:subjective_section | S | 0..1 | BackboneElement | Subjective Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Subjective 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61150-9 | |
| text | S | 1..1 | Narrative | This section contains only human readable content |
| section:vital_signs_section | S | 0..1 | BackboneElement | Vital Signs Section |
| title | S | 1..1 | string | title |
| code | S | 1..1 | CodeableConcept | Vital signs 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| text | S | 1..1 | Narrative | text |
| entry | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() | |
| entry:vital_signs_entry | S | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| Documentation for this format | ||||
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 | string | 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) Max Binding: AllLanguages |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| VersionNumber | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber |
| DataEntererExtension | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension |
| InformantExtension | 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 |
| InformationRecipientExtension | 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 |
| ParticipantExtension | 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 |
| PerformerExtension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension |
| AuthorizationExtension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension |
| OrderExtension | 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) |
| type | SΣ | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example) |
| 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 |
| 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..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) | |
| 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) 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) 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) 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) | |
| 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) |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 0..* | (Slice Definition) | 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) | |
| 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 | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:assessment_section | SI | 0..1 | BackboneElement | Assessment 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 | Assessments Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:allergies_and_intolerances_section | SI | 0..1 | BackboneElement | Allergies and Intolerances 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 | Allergies, adverse reactions, alerts Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| 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 | I | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:allergies_and_intolerances_entry | SI | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:assessment_and_plan_section | SI | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
| 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 | Assessment and plan Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:assessment_and_plan_entry | SI | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:chief_complaint_section | SI | 0..1 | BackboneElement | Chief Complaint 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 | Chief complaint Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:instructions_section | SI | 0..1 | BackboneElement | Instructions 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 | Instructions Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:interventions_section | SI | 0..1 | BackboneElement | Interventions 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 | Interventions provided Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 62387-6 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:interventions_section | SI | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:medications_section | SI | 0..1 | BackboneElement | Medications 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 | History of medication use Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:medications_entry | SI | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:nutrition_section | SI | 0..1 | BackboneElement | Nutrition 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 | Diet and nutrition Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | SI | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:nutrition_entry | SI | 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 | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:objective_section | SI | 0..1 | BackboneElement | Objective 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 | Objective Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:physical_exam_section | SI | 0..1 | BackboneElement | Physical Exam 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 | Physical findings Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:physical_exam_entry | SI | 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 | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:plan_of_treatment_section | SI | 0..1 | BackboneElement | Plan of Treatment 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 | Plan of Treatment Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:sliceEntry | I | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:problems_section | SI | 0..1 | BackboneElement | Problems 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 | Problem list Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:problem_entry | SI | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:results_section | SI | 0..1 | BackboneElement | Results 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 | Relevant diagnostic tests and/or laboratory data Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | SI | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:results_entry | SI | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:review_of_systems_section | SI | 0..1 | BackboneElement | Review of Systems 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 | Review of systems Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:subjective_section | SI | 0..1 | BackboneElement | Subjective 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 | Subjective Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61150-9 | |
| 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 | SI | 1..1 | Narrative | This section contains only human readable content |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:vital_signs_section | SI | 0..1 | BackboneElement | Vital Signs 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 | Vital signs Binding: DocumentSectionCodes (example) 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://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| 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 | SI | 1..1 | Narrative | text |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required) | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) | |
| entry | I | 0..* | (Slice Definition) | entry Slice: Unordered, Open by profile:resolve() |
| entry:vital_signs_entry | SI | 0..* | Reference(Vital Signs Profile) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| Composition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Composition.status | required | CompositionStatus |
| Composition.type | required | ProgressNoteDocumentTypeCode |
| 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 | v3.ActCode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section.mode | required | ListMode |
| Composition.section.orderedBy | preferred | ListOrderCodes |
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:assessment_section.code | example | Pattern: LOINC code 51848-0 |
| Composition.section:assessment_section.mode | required | ListMode |
| Composition.section:assessment_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC code 48765-2 |
| Composition.section:allergies_and_intolerances_section.mode | required | ListMode |
| Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC code 51847-2 |
| Composition.section:assessment_and_plan_section.mode | required | ListMode |
| Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:chief_complaint_section.code | example | Pattern: LOINC code 10154-3 |
| Composition.section:chief_complaint_section.mode | required | ListMode |
| Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:chief_complaint_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:instructions_section.code | example | Pattern: LOINC code 69730-0 |
| Composition.section:instructions_section.mode | required | ListMode |
| Composition.section:instructions_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:instructions_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:interventions_section.code | example | Pattern: LOINC code 62387-6 |
| Composition.section:interventions_section.mode | required | ListMode |
| Composition.section:interventions_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:interventions_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:medications_section.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:medications_section.mode | required | ListMode |
| Composition.section:medications_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:medications_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:nutrition_section.code | example | Pattern: LOINC code 61144-2 |
| Composition.section:nutrition_section.mode | required | ListMode |
| Composition.section:nutrition_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:nutrition_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:objective_section.code | example | Pattern: LOINC code 61149-1 |
| Composition.section:objective_section.mode | required | ListMode |
| Composition.section:objective_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:objective_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:physical_exam_section.code | example | Pattern: LOINC code 29545-1 |
| Composition.section:physical_exam_section.mode | required | ListMode |
| Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC code 18776-5 |
| Composition.section:plan_of_treatment_section.mode | required | ListMode |
| Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:problems_section.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:problems_section.mode | required | ListMode |
| Composition.section:problems_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:problems_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:results_section.code | example | Pattern: LOINC code 30954-2 |
| Composition.section:results_section.mode | required | ListMode |
| Composition.section:results_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:results_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:review_of_systems_section.code | example | Pattern: LOINC code 10187-3 |
| Composition.section:review_of_systems_section.mode | required | ListMode |
| Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:subjective_section.code | example | Pattern: LOINC code 61150-9 |
| Composition.section:subjective_section.mode | required | ListMode |
| Composition.section:subjective_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:subjective_section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:vital_signs_section.code | example | Pattern: LOINC code 8716-3 |
| Composition.section:vital_signs_section.mode | required | ListMode |
| Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodes |
| Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasons |
| Id | Path | Details | Requirements |
| dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | 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 | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Composition.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:versionNumber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:versionNumber | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:version_number_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:version_number_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:data_enterer_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:data_enterer_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:informant_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:informant_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:information_recipient_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:information_recipient_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:participant_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:participant_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:performer_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:performer_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:authorization_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:authorization_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:order_extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:order_extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.date | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:legal_attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:legal_attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester:legal_attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester:legal_attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester:legal_attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester:legal_attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:legal_attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:legal_attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:professional_attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:professional_attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester:professional_attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester:professional_attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester:professional_attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester:professional_attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:professional_attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:professional_attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:personal_attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:personal_attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester:personal_attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester:personal_attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester:personal_attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester:personal_attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:personal_attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester:personal_attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.custodian | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.target[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:assessment_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:assessment_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:assessment_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:assessment_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:assessment_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:assessment_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:assessment_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:allergies_and_intolerances_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:allergies_and_intolerances_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:allergies_and_intolerances_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:allergies_and_intolerances_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:allergies_and_intolerances_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:allergies_and_intolerances_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:allergies_and_intolerances_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.entry:allergies_and_intolerances_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:allergies_and_intolerances_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:assessment_and_plan_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:assessment_and_plan_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:assessment_and_plan_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:assessment_and_plan_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:assessment_and_plan_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:assessment_and_plan_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:assessment_and_plan_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.entry:assessment_and_plan_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:assessment_and_plan_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:chief_complaint_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:chief_complaint_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:chief_complaint_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:chief_complaint_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:chief_complaint_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:chief_complaint_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:chief_complaint_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:chief_complaint_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:instructions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:instructions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:instructions_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:instructions_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:instructions_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:instructions_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:instructions_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:instructions_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:interventions_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:interventions_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:interventions_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:interventions_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:interventions_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:interventions_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:interventions_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.entry:interventions_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:interventions_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:medications_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:medications_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:medications_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:medications_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:medications_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:medications_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:medications_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.entry:medications_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medications_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:nutrition_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:nutrition_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:nutrition_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:nutrition_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:nutrition_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:nutrition_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:nutrition_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.entry:nutrition_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:nutrition_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:objective_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:objective_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:objective_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:objective_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:objective_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:objective_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:objective_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:objective_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:physical_exam_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:physical_exam_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:physical_exam_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:physical_exam_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:physical_exam_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:physical_exam_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:physical_exam_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.entry:physical_exam_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:physical_exam_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:plan_of_treatment_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:plan_of_treatment_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:plan_of_treatment_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:plan_of_treatment_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:plan_of_treatment_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:plan_of_treatment_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:plan_of_treatment_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.entry:sliceEntry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:plan_of_treatment_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:problems_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:problems_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:problems_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:problems_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:problems_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:problems_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:problems_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.entry:problem_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problems_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:results_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:results_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:results_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:results_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:results_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:results_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:results_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.entry:results_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:results_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:review_of_systems_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:review_of_systems_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:review_of_systems_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:review_of_systems_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:review_of_systems_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:review_of_systems_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:review_of_systems_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:review_of_systems_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:subjective_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:subjective_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:subjective_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:subjective_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:subjective_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:subjective_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:subjective_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:subjective_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:vital_signs_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:vital_signs_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:vital_signs_section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:vital_signs_section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:vital_signs_section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:vital_signs_section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:vital_signs_section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.entry:vital_signs_entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:vital_signs_section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2020+ HL7 Structured Documents Working Group. Package hl7.fhir.us.ccda#1.1.0 based on FHIR 4.0.1. Generated 2020-10-21
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