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
The official URL for this profile is:
http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note
This profile represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.
Taber's medical dictionary defines a Progress Note as An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.
Mosby's medical dictionary defines a Progress Note as Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned.
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.
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
Summary
Mandatory: 0 element (48 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) | |
section | BackboneElement | Slice: Unordered, Open by value:code | ||
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core AllergyIntolerance Profile) | ||
section | 0..1 | BackboneElement | Assessment 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..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and plan Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief complaint Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Required Pattern: {"coding":[{"system":"http://loinc.org","code":"69730-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Interventions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Interventions provided Required Pattern: {"coding":[{"system":"http://loinc.org","code":"62387-6"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core MedicationStatement Profile) | ||
section | 0..1 | BackboneElement | Nutrition Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Diet and nutrition Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Objective Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Objective Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61149-1"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical findings Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Problems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem list Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | ||
section | 0..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Results Profile) | ||
section | 0..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of systems Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Subjective Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Subjective Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61150-9"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital signs Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(VitalSigns) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | Σ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 1..1 | code | language Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
CCDA-on-FHIR-Data-Enterer | I | 0..1 | Reference(US Core Practitioner Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile) | Value of extension | |
CCDA-on-FHIR-Informant | I | 0..* | 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..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson) | Value of extension | |
CCDA-on-FHIR-Information-Recipient | I | 0..* | Reference(US Core Practitioner Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile) | Value of extension | |
CCDA-on-FHIR-Participant | I | 0..* | 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..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Participant" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson) | Value of extension | |
CCDA-on-FHIR-Performer | I | 0..* | Reference(US Core Practitioner Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile) | Value of extension | |
CCDA-on-FHIR-Authorization | I | 0..* | Reference(C-CDA on FHIR Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization" | |
valueReference | 0..1 | Reference(C-CDA on FHIR Consent) | Value of extension | |
CCDA-on-FHIR-In-Fulfillment-Of-Order | I | 0..* | Reference(ProcedureRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order" | |
valueReference | 0..1 | Reference(ProcedureRequest) | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 1..1 | Identifier | identifier |
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
type | Σ | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) |
class | Σ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
subject | Σ | 1..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about |
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
date | Σ | 1..1 | dateTime | date |
author | Σ | 1..* | Reference(US Core Practitioner Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Document Title |
confidentiality | ?!Σ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
attester | ΣI | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..* | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 0..1 | Reference(Patient | Practitioner | Organization) | Who attested the composition |
attester | ΣI | 0..1 | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..1 | code | mode Binding: CompositionAttestationMode (required) Fixed Value: legal |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 1..1 | Reference(US Core Practitioner Profile) | party |
attester | ΣI | 0..* | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..* | code | mode Binding: CompositionAttestationMode (required) Fixed Value: professional |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 1..1 | Reference(US Core Practitioner Profile) | party |
attester | ΣI | 0..* | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..* | code | mode Binding: CompositionAttestationMode (required) Fixed Value: personal |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 1..1 | Reference(US Core Patient Profile) | party |
custodian | Σ | 1..1 | Reference(US Core Organization Profile) | custodian |
relatesTo | ΣI | 0..* | BackboneElement | Relationships to other compositions/documents |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
target[x] | Σ | 1..1 | Identifier, Reference(Composition) | Target of the relationship |
event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 0..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) | |
text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
section | I | 0..1 | BackboneElement | Assessment Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:assessment_section Nested Section | |
section | I | 0..1 | BackboneElement | Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:allergies_and_intolerances_section Nested Section | |
section | I | 0..1 | BackboneElement | Assessment 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..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and plan Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:reference | |
entry | I | 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. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:assessment_and_plan_section Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief complaint Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:chief_complaint_section Nested Section | |
section | I | 0..1 | BackboneElement | Instructions Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"69730-0"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:instructions_section Nested Section | |
section | I | 0..1 | BackboneElement | Interventions Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Interventions provided Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"62387-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:interventions_section Nested Section | |
section | I | 0..1 | BackboneElement | Medications Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core MedicationStatement Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:medications_section Nested Section | |
section | I | 0..1 | BackboneElement | Nutrition Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Diet and nutrition Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:nutrition_section Nested Section | |
section | I | 0..1 | BackboneElement | Objective Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Objective Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61149-1"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:objective_section Nested Section | |
section | I | 0..1 | BackboneElement | Physical Exam Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical findings Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:physical_exam_section Nested Section | |
section | I | 0..1 | BackboneElement | Plan of Treatment Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 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. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:plan_of_treatment_section Nested Section | |
section | I | 0..1 | BackboneElement | Problems Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem list Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:problems_section Nested Section | |
section | I | 0..1 | BackboneElement | Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core Results Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:results_section Nested Section | |
section | I | 0..1 | BackboneElement | Review of Systems Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of systems Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:review_of_systems_section Nested Section | |
section | I | 0..1 | BackboneElement | Subjective Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Subjective Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61150-9"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:subjective_section Nested Section | |
section | I | 0..1 | BackboneElement | Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital signs Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(VitalSigns) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:vital_signs_section Nested Section | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 0 element (48 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) | |
section | BackboneElement | Slice: Unordered, Open by value:code | ||
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core AllergyIntolerance Profile) | ||
section | 0..1 | BackboneElement | Assessment 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..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and plan Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief complaint Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Required Pattern: {"coding":[{"system":"http://loinc.org","code":"69730-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Interventions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Interventions provided Required Pattern: {"coding":[{"system":"http://loinc.org","code":"62387-6"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core MedicationStatement Profile) | ||
section | 0..1 | BackboneElement | Nutrition Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Diet and nutrition Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Objective Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Objective Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61149-1"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical findings Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | Problems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem list Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | ||
section | 0..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Results Profile) | ||
section | 0..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of systems Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Subjective Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Subjective Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61150-9"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital signs Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(VitalSigns) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | Σ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 1..1 | code | language Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
CCDA-on-FHIR-Data-Enterer | I | 0..1 | Reference(US Core Practitioner Profile) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile) | Value of extension | |
CCDA-on-FHIR-Informant | I | 0..* | 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..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson) | Value of extension | |
CCDA-on-FHIR-Information-Recipient | I | 0..* | Reference(US Core Practitioner Profile) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile) | Value of extension | |
CCDA-on-FHIR-Participant | I | 0..* | 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..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Participant" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile | US Core Patient Profile | RelatedPerson) | Value of extension | |
CCDA-on-FHIR-Performer | I | 0..* | Reference(US Core Practitioner Profile) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer" | |
valueReference | 0..1 | Reference(US Core Practitioner Profile) | Value of extension | |
CCDA-on-FHIR-Authorization | I | 0..* | Reference(C-CDA on FHIR Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization" | |
valueReference | 0..1 | Reference(C-CDA on FHIR Consent) | Value of extension | |
CCDA-on-FHIR-In-Fulfillment-Of-Order | I | 0..* | Reference(ProcedureRequest) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order" | |
valueReference | 0..1 | Reference(ProcedureRequest) | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 1..1 | Identifier | identifier |
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
type | Σ | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) |
class | Σ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
subject | Σ | 1..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about |
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
date | Σ | 1..1 | dateTime | date |
author | Σ | 1..* | Reference(US Core Practitioner Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Document Title |
confidentiality | ?!Σ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
attester | ΣI | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..* | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 0..1 | Reference(Patient | Practitioner | Organization) | Who attested the composition |
attester | ΣI | 0..1 | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..1 | code | mode Binding: CompositionAttestationMode (required) Fixed Value: legal |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 1..1 | Reference(US Core Practitioner Profile) | party |
attester | ΣI | 0..* | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..* | code | mode Binding: CompositionAttestationMode (required) Fixed Value: professional |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 1..1 | Reference(US Core Practitioner Profile) | party |
attester | ΣI | 0..* | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | Σ | 1..* | code | mode Binding: CompositionAttestationMode (required) Fixed Value: personal |
time | Σ | 0..1 | dateTime | When the composition was attested |
party | Σ | 1..1 | Reference(US Core Patient Profile) | party |
custodian | Σ | 1..1 | Reference(US Core Organization Profile) | custodian |
relatesTo | ΣI | 0..* | BackboneElement | Relationships to other compositions/documents |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
target[x] | Σ | 1..1 | Identifier, Reference(Composition) | Target of the relationship |
event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 0..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) | |
text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
section | I | 0..1 | BackboneElement | Assessment Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:assessment_section Nested Section | |
section | I | 0..1 | BackboneElement | Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:allergies_and_intolerances_section Nested Section | |
section | I | 0..1 | BackboneElement | Assessment 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..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and plan Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:reference | |
entry | I | 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. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:assessment_and_plan_section Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief complaint Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:chief_complaint_section Nested Section | |
section | I | 0..1 | BackboneElement | Instructions Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"69730-0"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:instructions_section Nested Section | |
section | I | 0..1 | BackboneElement | Interventions Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Interventions provided Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"62387-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:interventions_section Nested Section | |
section | I | 0..1 | BackboneElement | Medications Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core MedicationStatement Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:medications_section Nested Section | |
section | I | 0..1 | BackboneElement | Nutrition Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Diet and nutrition Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:nutrition_section Nested Section | |
section | I | 0..1 | BackboneElement | Objective Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Objective Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61149-1"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:objective_section Nested Section | |
section | I | 0..1 | BackboneElement | Physical Exam Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical findings Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:physical_exam_section Nested Section | |
section | I | 0..1 | BackboneElement | Plan of Treatment Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 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. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:plan_of_treatment_section Nested Section | |
section | I | 0..1 | BackboneElement | Problems Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem list Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:problems_section Nested Section | |
section | I | 0..1 | BackboneElement | Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(US Core Results Profile) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:results_section Nested Section | |
section | I | 0..1 | BackboneElement | Review of Systems Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of systems Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:review_of_systems_section Nested Section | |
section | I | 0..1 | BackboneElement | Subjective Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Subjective Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61150-9"}]} | |
text | I | 1..1 | Narrative | This section contains only human readable content |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:subjective_section Nested Section | |
section | I | 0..1 | BackboneElement | Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital signs Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | |
entry | I | 0..* | Reference(VitalSigns) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section:vital_signs_section Nested Section | |
Documentation for this format |
Path | Name | Conformance | ValueSet |
Composition.language | Common Languages | extensible | Common Languages |
Composition.status | CompositionStatus | required | CompositionStatus |
Composition.type | ProgressNoteDocumentTypeCode | required | ProgressNoteDocumentTypeCode |
Composition.class | FHIR Document Class Codes | example | FHIR Document Class Codes |
Composition.confidentiality | ConfidentialityClassification | required | ConfidentialityClassification |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.relatesTo.code | DocumentRelationshipType | required | DocumentRelationshipType |
Composition.event.code | v3 Code System ActCode | example | v3 Code System ActCode |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Id | Path | Details | Requirements |
dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-1 | Composition | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
dom-4 | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-3 | Composition | If 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-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | Composition.relatesTo | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | Composition.event | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() |