C-CDA on FHIR Implementation Guide STU 1 (v1.0.0)

This page is part of the C-CDA on FHIR Implementation Guide (v1.0.0: STU 1) based on FHIR R3. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: CCDA-on-FHIR-Consultation-Note

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Consultation-Note

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.

A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).

This profile builds on C-CDA on FHIR US Realm Header.

This profile was published on Sat Apr 07 06:53:01 AEST 2018 as a draft by Lantana Consulting Group.

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

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptConsultation Note
Binding: ConsultDocumentType (required)
... encounter 1..1Reference(Encounter)encompassingEncounter
... section BackboneElementSlice: Unordered, Open by value:code
... section 1..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and adverse reactions
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core AllergyIntolerance Profile)
... section 1..1BackboneElementHistory of Present Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of present illness
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementProblem Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) Profile)
... section 0..1BackboneElementMedications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementPhysical Exam Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 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 0..1BackboneElementResults Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests/laboratory data
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Results Profile)
... section 0..1BackboneElementAdvance Directives Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAdvance directives
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(Consent)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s 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..1stringtitle
.... code 1..1CodeableConceptAssessment (evaluation) and plan
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) 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 0..1BackboneElementAssessment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments (evaluation)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint and reason for visit
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46239-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementChief Complaint Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementFamily History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptFamily history
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10157-6"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementFunctional Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 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 0..1BackboneElementGeneral Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings of General status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10210-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHistory of Past Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of past illness
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) Profile)
... section 0..1BackboneElementImmunizations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of immunization
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Immunization Profile)
... section 0..1BackboneElementMedical Equipment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medical device use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(Device)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementMental Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMental status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10190-7"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 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 0..1BackboneElementNutrition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(NutritionOrder | ClinicalImpression)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ProcedureRequest | 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 0..1BackboneElementProcedures Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of Procedures
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Procedure Profile)
... section 0..1BackboneElementReason for Visit Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReason for visit
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29299-5"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementReview of Systems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementSocial History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Smoking Status Profile | Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementVital Signs Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(VitalSigns)

doco Documentation for this format

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... CCDA-on-FHIR-Data-Enterer I0..1Reference(US Core Practitioner Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer"
.... valueReference 0..1Reference(US Core Practitioner Profile)Value of extension
... CCDA-on-FHIR-Informant I0..*Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant"
.... valueReference 0..1Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)Value of extension
... CCDA-on-FHIR-Information-Recipient I0..*Reference(US Core Practitioner Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient"
.... valueReference 0..1Reference(US Core Practitioner Profile)Value of extension
... CCDA-on-FHIR-Participant I0..*Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Participant
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Participant"
.... valueReference 0..1Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)Value of extension
... CCDA-on-FHIR-Performer I0..*Reference(US Core Practitioner Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer"
.... valueReference 0..1Reference(US Core Practitioner Profile)Value of extension
... CCDA-on-FHIR-Authorization I0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization"
.... valueReference 0..1Reference(C-CDA on FHIR Consent)Value of extension
... CCDA-on-FHIR-In-Fulfillment-Of-Order I0..*Reference(ProcedureRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order"
.... valueReference 0..1Reference(ProcedureRequest)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ1..1Identifieridentifier
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type Σ1..1CodeableConceptConsultation Note
Binding: ConsultDocumentType (required)
... class Σ0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... subject Σ1..1Reference(US Core Patient Profile | Group)Who and/or what the composition is about
... encounter Σ1..1Reference(Encounter)encompassingEncounter
... date Σ1..1dateTimedate
... author Σ1..*Reference(US Core Practitioner Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson)Who and/or what authored the composition
... title Σ1..1stringDocument Title
... confidentiality ?!Σ1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... attester ΣIBackboneElementAttests to accuracy of composition
Slice: Unordered, Open by value:mode
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ0..1Reference(Patient | Practitioner | Organization)Who attested the composition
... attester ΣI0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..1codemode
Binding: CompositionAttestationMode (required)

Fixed Value: legal
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ1..1Reference(US Core Practitioner Profile)party
... attester ΣI0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codemode
Binding: CompositionAttestationMode (required)

Fixed Value: professional
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ1..1Reference(US Core Practitioner Profile)party
... attester ΣI0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codemode
Binding: CompositionAttestationMode (required)

Fixed Value: personal
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ1..1Reference(US Core Patient Profile)party
... custodian Σ1..1Reference(US Core Organization Profile)custodian
... relatesTo ΣI0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] Σ1..1Identifier, Reference(Composition)Target of the relationship
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example)
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section
Nested Section
... section I1..1BackboneElementAllergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and adverse reactions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core AllergyIntolerance Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:allergies_and_intolerances_section
Nested Section
... section I1..1BackboneElementHistory of Present Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of present illness
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:history_of_present_illness_section
Nested Section
... section I1..1BackboneElementProblem Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:problem_section
Nested Section
... section I0..1BackboneElementMedications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core MedicationStatement Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medications_section
Nested Section
... section I0..1BackboneElementPhysical Exam Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:physical_exam_section
Nested Section
... section I0..1BackboneElementResults Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests/laboratory data
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Results Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:results_section
Nested Section
... section I0..1BackboneElementAdvance Directives Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAdvance directives
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Consent)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:advance_directive_section
Nested Section
... section I0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment (evaluation) and plan
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) 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 I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_and_plan_section
Nested Section
... section I0..1BackboneElementAssessment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments (evaluation)
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_section
Nested Section
... section I0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint and reason for visit
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46239-0"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:chief_complaint_and_reason_for_visit_section
Nested Section
... section I0..1BackboneElementChief Complaint Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:chief_complaint_section
Nested Section
... section I0..1BackboneElementFamily History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptFamily history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10157-6"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:family_history_section
Nested Section
... section I0..1BackboneElementFunctional Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:functional_status_section
Nested Section
... section I0..1BackboneElementGeneral Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings of General status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10210-3"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:general_status_section
Nested Section
... section I0..1BackboneElementHistory of Past Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of past illness
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:history_of_past_illness_section
Nested Section
... section I0..1BackboneElementImmunizations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of immunization
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Immunization Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:immunizations_section
Nested Section
... section I0..1BackboneElementMedical Equipment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medical device use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Device)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medical_equipment_section
Nested Section
... section I0..1BackboneElementMental Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptMental status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10190-7"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:mental_status_section
Nested Section
... section I0..1BackboneElementNutrition Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(NutritionOrder | ClinicalImpression)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:nutrition_section
Nested Section
... section I0..1BackboneElementPlan of Treatment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ProcedureRequest | 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 I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:plan_of_treatment_section
Nested Section
... section I0..1BackboneElementProcedures Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of Procedures
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Procedure Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:procedures_section
Nested Section
... section I0..1BackboneElementReason for Visit Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReason for visit
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29299-5"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:reason_for_visit_section
Nested Section
... section I0..1BackboneElementReview of Systems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:review_of_systems_section
Nested Section
... section I0..1BackboneElementSocial History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Smoking Status Profile | Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:social_history_section
Nested Section
... section I0..1BackboneElementVital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(VitalSigns)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:vital_signs_section
Nested Section

doco Documentation for this format

Differential View

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptConsultation Note
Binding: ConsultDocumentType (required)
... encounter 1..1Reference(Encounter)encompassingEncounter
... section BackboneElementSlice: Unordered, Open by value:code
... section 1..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and adverse reactions
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core AllergyIntolerance Profile)
... section 1..1BackboneElementHistory of Present Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of present illness
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementProblem Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) Profile)
... section 0..1BackboneElementMedications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementPhysical Exam Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 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 0..1BackboneElementResults Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests/laboratory data
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Results Profile)
... section 0..1BackboneElementAdvance Directives Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAdvance directives
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(Consent)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s 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..1stringtitle
.... code 1..1CodeableConceptAssessment (evaluation) and plan
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) 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 0..1BackboneElementAssessment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments (evaluation)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint and reason for visit
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46239-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementChief Complaint Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementFamily History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptFamily history
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10157-6"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementFunctional Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 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 0..1BackboneElementGeneral Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings of General status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10210-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHistory of Past Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of past illness
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) Profile)
... section 0..1BackboneElementImmunizations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of immunization
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Immunization Profile)
... section 0..1BackboneElementMedical Equipment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medical device use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(Device)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementMental Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMental status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10190-7"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 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 0..1BackboneElementNutrition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(NutritionOrder | ClinicalImpression)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ProcedureRequest | 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 0..1BackboneElementProcedures Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of Procedures
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Procedure Profile)
... section 0..1BackboneElementReason for Visit Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReason for visit
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29299-5"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementReview of Systems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementSocial History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Smoking Status Profile | Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementVital Signs Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(VitalSigns)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... CCDA-on-FHIR-Data-Enterer I0..1Reference(US Core Practitioner Profile)Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer"
.... valueReference 0..1Reference(US Core Practitioner Profile)Value of extension
... CCDA-on-FHIR-Informant I0..*Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant"
.... valueReference 0..1Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)Value of extension
... CCDA-on-FHIR-Information-Recipient I0..*Reference(US Core Practitioner Profile)informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient"
.... valueReference 0..1Reference(US Core Practitioner Profile)Value of extension
... CCDA-on-FHIR-Participant I0..*Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Participant
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Participant"
.... valueReference 0..1Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson)Value of extension
... CCDA-on-FHIR-Performer I0..*Reference(US Core Practitioner Profile)performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer"
.... valueReference 0..1Reference(US Core Practitioner Profile)Value of extension
... CCDA-on-FHIR-Authorization I0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization"
.... valueReference 0..1Reference(C-CDA on FHIR Consent)Value of extension
... CCDA-on-FHIR-In-Fulfillment-Of-Order I0..*Reference(ProcedureRequest)authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order"
.... valueReference 0..1Reference(ProcedureRequest)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ1..1Identifieridentifier
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type Σ1..1CodeableConceptConsultation Note
Binding: ConsultDocumentType (required)
... class Σ0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... subject Σ1..1Reference(US Core Patient Profile | Group)Who and/or what the composition is about
... encounter Σ1..1Reference(Encounter)encompassingEncounter
... date Σ1..1dateTimedate
... author Σ1..*Reference(US Core Practitioner Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson)Who and/or what authored the composition
... title Σ1..1stringDocument Title
... confidentiality ?!Σ1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... attester ΣIBackboneElementAttests to accuracy of composition
Slice: Unordered, Open by value:mode
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ0..1Reference(Patient | Practitioner | Organization)Who attested the composition
... attester ΣI0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..1codemode
Binding: CompositionAttestationMode (required)

Fixed Value: legal
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ1..1Reference(US Core Practitioner Profile)party
... attester ΣI0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codemode
Binding: CompositionAttestationMode (required)

Fixed Value: professional
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ1..1Reference(US Core Practitioner Profile)party
... attester ΣI0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codemode
Binding: CompositionAttestationMode (required)

Fixed Value: personal
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ1..1Reference(US Core Patient Profile)party
... custodian Σ1..1Reference(US Core Organization Profile)custodian
... relatesTo ΣI0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] Σ1..1Identifier, Reference(Composition)Target of the relationship
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open by value:code
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example)
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section
Nested Section
... section I1..1BackboneElementAllergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and adverse reactions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core AllergyIntolerance Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:allergies_and_intolerances_section
Nested Section
... section I1..1BackboneElementHistory of Present Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of present illness
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:history_of_present_illness_section
Nested Section
... section I1..1BackboneElementProblem Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:problem_section
Nested Section
... section I0..1BackboneElementMedications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core MedicationStatement Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medications_section
Nested Section
... section I0..1BackboneElementPhysical Exam Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:physical_exam_section
Nested Section
... section I0..1BackboneElementResults Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests/laboratory data
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Results Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:results_section
Nested Section
... section I0..1BackboneElementAdvance Directives Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAdvance directives
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Consent)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:advance_directive_section
Nested Section
... section I0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment (evaluation) and plan
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) 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 I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_and_plan_section
Nested Section
... section I0..1BackboneElementAssessment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments (evaluation)
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_section
Nested Section
... section I0..1BackboneElementChief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint and reason for visit
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46239-0"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:chief_complaint_and_reason_for_visit_section
Nested Section
... section I0..1BackboneElementChief Complaint Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:chief_complaint_section
Nested Section
... section I0..1BackboneElementFamily History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptFamily history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10157-6"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(FamilyMemberHistory)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:family_history_section
Nested Section
... section I0..1BackboneElementFunctional Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:functional_status_section
Nested Section
... section I0..1BackboneElementGeneral Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings of General status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10210-3"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:general_status_section
Nested Section
... section I0..1BackboneElementHistory of Past Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of past illness
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:history_of_past_illness_section
Nested Section
... section I0..1BackboneElementImmunizations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of immunization
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Immunization Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:immunizations_section
Nested Section
... section I0..1BackboneElementMedical Equipment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medical device use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Device)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medical_equipment_section
Nested Section
... section I0..1BackboneElementMental Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptMental status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10190-7"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:mental_status_section
Nested Section
... section I0..1BackboneElementNutrition Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(NutritionOrder | ClinicalImpression)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:nutrition_section
Nested Section
... section I0..1BackboneElementPlan of Treatment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Goal Profile | US Core MedicationRequest Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ProcedureRequest | 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 I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:plan_of_treatment_section
Nested Section
... section I0..1BackboneElementProcedures Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of Procedures
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Procedure Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:procedures_section
Nested Section
... section I0..1BackboneElementReason for Visit Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReason for visit
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29299-5"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:reason_for_visit_section
Nested Section
... section I0..1BackboneElementReview of Systems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:review_of_systems_section
Nested Section
... section I0..1BackboneElementSocial History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Smoking Status Profile | Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:social_history_section
Nested Section
... section I0..1BackboneElementVital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(VitalSigns)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:vital_signs_section
Nested Section

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Composition.languageCommon LanguagesextensibleCommon Languages
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.typeConsultDocumentTyperequiredConsultDocumentType
Composition.classFHIR Document Class CodesexampleFHIR Document Class Codes
Composition.confidentialityConfidentialityClassificationrequiredConfidentialityClassification
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.relatesTo.codeDocumentRelationshipTyperequiredDocumentRelationshipType
Composition.event.codev3 Code System ActCodeexamplev3 Code System ActCode
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2CompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1CompositionIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4CompositionIf 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-3CompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Composition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Composition.attesterAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1Composition.attesterAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1Composition.attesterAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1Composition.attesterAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1Composition.relatesToAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1Composition.eventAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1Composition.sectionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
.