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. This is the current published version. For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: CCDA-on-FHIR-Discharge-Summary

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-Discharge-Summary

The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/):

The reason for hospitalization (the admission)

The procedures performed, as applicable

The care, treatment, and services provided

The patients condition and disposition at discharge

Information provided to the patient and family

Provisions for follow-up care

The best practice for a Discharge Summary is to include the discharge disposition in the display of the header.

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..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (required)
... 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..1BackboneElementHospital Course Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8648-8"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementDischarge Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge diagnosis
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11535-2"}]}
.... 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..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..1BackboneElementDischarge Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge medications
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10183-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementAdmission Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital admission diagnosis
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46241-6"}]}
.... 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..1BackboneElementAdmission Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications on admission
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... 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..1CodeableConceptcode
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..1CodeableConceptcode
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..1CodeableConceptcode
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(US Core Condition (a.k.a Problem) Profile | Observation | 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..1BackboneElementHistory of Past Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
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..1BackboneElementHistory of Present Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Consultations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital consultations
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18841-7"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Discharge Instructions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge instructions
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8653-8"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Discharge Physical Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge physical
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10184-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Discharge Studies Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge studies summary
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11493-4"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementImmunizations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptImmunizations
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..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(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..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..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..1CodeableConceptcode
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)
... section 0..1BackboneElementGoals Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptGoals
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61146-7"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Goal Profile)entry
... section 0..1BackboneElementHealth Concerns Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHealth concerns section code
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"75310-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core AllergyIntolerance Profile | US Core Condition (a.k.a Problem) Profile | US Core Results Profile | US Core Smoking Status Profile | VitalSigns | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

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..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (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 Σ0..1Reference(Encounter)Context of the Composition
... 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..1BackboneElementHospital Course 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..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8648-8"}]}
.... 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:hospital_course_section
Nested Section
... section I1..1BackboneElementDischarge Diagnosis 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..1CodeableConceptHospital discharge diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11535-2"}]}
.... 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 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:discharge_diagnosis_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..1BackboneElementDischarge Medications 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..1CodeableConceptHospital discharge medications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10183-2"}]}
.... 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 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:discharge_medications_section
Nested Section
... section I0..1BackboneElementAdmission Diagnosis 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..1CodeableConceptHospital admission diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46241-6"}]}
.... 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 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:admission_diagnosis_section
Nested Section
... section I0..1BackboneElementAdmission Medications 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..1CodeableConceptMedications on admission
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]}
.... 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(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:admission_medications_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..1CodeableConceptcode
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..1CodeableConceptcode
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..1CodeableConceptcode
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(US Core Condition (a.k.a Problem) Profile | Observation | 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:functional_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..1CodeableConceptcode
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..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..1CodeableConceptcode
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 I0..1BackboneElementHospital Consultations 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..1CodeableConceptHospital consultations
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18841-7"}]}
.... 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:hospital_consultations_section
Nested Section
... section I0..1BackboneElementHospital Discharge Instructions 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..1CodeableConceptHospital discharge instructions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8653-8"}]}
.... 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:hospital_discharge_instructions_section
Nested Section
... section I0..1BackboneElementHospital Discharge Physical 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..1CodeableConceptHospital discharge physical
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10184-0"}]}
.... 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:hospital_discharge_physical_section
Nested Section
... section I0..1BackboneElementHospital Discharge Studies 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..1CodeableConceptHospital discharge studies summary
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11493-4"}]}
.... 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:hospital_discharge_studies_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..1CodeableConceptImmunizations
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..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(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:nutrition_section
Nested Section
... section I0..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..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..1CodeableConceptcode
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
... section I0..1BackboneElementGoals 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..1CodeableConceptGoals
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61146-7"}]}
.... 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(US Core Goal Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:goals_section
Nested Section
... section I0..1BackboneElementHealth Concerns 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..1CodeableConceptHealth concerns section code
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"75310-3"}]}
.... 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(US Core AllergyIntolerance Profile | US Core Condition (a.k.a Problem) Profile | US Core Results Profile | US Core Smoking Status Profile | VitalSigns | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:health_concerns_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..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (required)
... 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..1BackboneElementHospital Course Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8648-8"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementDischarge Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge diagnosis
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11535-2"}]}
.... 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..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..1BackboneElementDischarge Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge medications
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10183-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementAdmission Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital admission diagnosis
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46241-6"}]}
.... 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..1BackboneElementAdmission Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications on admission
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... 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..1CodeableConceptcode
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..1CodeableConceptcode
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..1CodeableConceptcode
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(US Core Condition (a.k.a Problem) Profile | Observation | 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..1BackboneElementHistory of Past Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
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..1BackboneElementHistory of Present Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Consultations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital consultations
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18841-7"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Discharge Instructions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge instructions
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8653-8"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Discharge Physical Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge physical
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10184-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementHospital Discharge Studies Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge studies summary
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11493-4"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementImmunizations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptImmunizations
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..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(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..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..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..1CodeableConceptcode
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)
... section 0..1BackboneElementGoals Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptGoals
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61146-7"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Goal Profile)entry
... section 0..1BackboneElementHealth Concerns Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHealth concerns section code
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"75310-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core AllergyIntolerance Profile | US Core Condition (a.k.a Problem) Profile | US Core Results Profile | US Core Smoking Status Profile | VitalSigns | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

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..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (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 Σ0..1Reference(Encounter)Context of the Composition
... 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..1BackboneElementHospital Course 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..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8648-8"}]}
.... 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:hospital_course_section
Nested Section
... section I1..1BackboneElementDischarge Diagnosis 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..1CodeableConceptHospital discharge diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11535-2"}]}
.... 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 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:discharge_diagnosis_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..1BackboneElementDischarge Medications 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..1CodeableConceptHospital discharge medications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10183-2"}]}
.... 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 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:discharge_medications_section
Nested Section
... section I0..1BackboneElementAdmission Diagnosis 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..1CodeableConceptHospital admission diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46241-6"}]}
.... 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 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:admission_diagnosis_section
Nested Section
... section I0..1BackboneElementAdmission Medications 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..1CodeableConceptMedications on admission
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]}
.... 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(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:admission_medications_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..1CodeableConceptcode
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..1CodeableConceptcode
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..1CodeableConceptcode
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(US Core Condition (a.k.a Problem) Profile | Observation | 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:functional_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..1CodeableConceptcode
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..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..1CodeableConceptcode
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 I0..1BackboneElementHospital Consultations 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..1CodeableConceptHospital consultations
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18841-7"}]}
.... 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:hospital_consultations_section
Nested Section
... section I0..1BackboneElementHospital Discharge Instructions 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..1CodeableConceptHospital discharge instructions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8653-8"}]}
.... 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:hospital_discharge_instructions_section
Nested Section
... section I0..1BackboneElementHospital Discharge Physical 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..1CodeableConceptHospital discharge physical
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10184-0"}]}
.... 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:hospital_discharge_physical_section
Nested Section
... section I0..1BackboneElementHospital Discharge Studies 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..1CodeableConceptHospital discharge studies summary
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11493-4"}]}
.... 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:hospital_discharge_studies_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..1CodeableConceptImmunizations
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..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(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:nutrition_section
Nested Section
... section I0..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..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..1CodeableConceptcode
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
... section I0..1BackboneElementGoals 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..1CodeableConceptGoals
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61146-7"}]}
.... 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(US Core Goal Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:goals_section
Nested Section
... section I0..1BackboneElementHealth Concerns 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..1CodeableConceptHealth concerns section code
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"75310-3"}]}
.... 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(US Core AllergyIntolerance Profile | US Core Condition (a.k.a Problem) Profile | US Core Results Profile | US Core Smoking Status Profile | VitalSigns | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:health_concerns_section
Nested Section

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Composition.languageCommon LanguagesextensibleCommon Languages
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.typeDischargeSummaryDocumentTypeCoderequiredDischargeSummaryDocumentTypeCode
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
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()
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()
.