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-Procedure-Note

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

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

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.

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

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

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

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

Summary

Mandatory: 20 elements (72 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptProcedure Note
Binding: ProcedureNoteDocumentTypeCodes (required)
... event 1..*BackboneElementserviceEvent
.... period 1..1Periodperiod
..... start 1..1dateTimestart
..... end 1..1dateTimeend
... section BackboneElementSlice: Unordered, Open by value:code
... section 1..1BackboneElementComplications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptComplications
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"55109-3"}]}
.... 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 1..1BackboneElementProcedure Description Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure description
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementProcedure Indications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure indications
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59768-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementPostprocedure Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPostprocedure diagnosis
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59769-0"}]}
.... 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..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and/or 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 0..1BackboneElementAssessment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementAnesthesia Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAnesthesia
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59774-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile | US Core Procedure 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..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..1BackboneElementMedical (General) History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedical (general) history
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11329-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementMedications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementMedications Administered Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications administered
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementPhysical Exam Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..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..1BackboneElementPlanned Procedure Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlanned procedure
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59772-4"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Disposition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure disposition
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59775-7"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Estimated Blood Loss Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure estimated blood loss
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59770-8"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Findings Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59776-5"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Implants Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure implants
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59771-6"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Specimens Taken Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure specimens taken
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59773-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... 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.

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..1CodeableConceptProcedure Note
Binding: ProcedureNoteDocumentTypeCodes (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 ΣI1..*BackboneElementserviceEvent
.... 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 Σ1..1Periodperiod
..... id 0..1stringxml:id (or equivalent in JSON)
..... start ΣI1..1dateTimestart
..... end ΣI1..1dateTimeend
.... 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..1BackboneElementComplications 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..1CodeableConceptComplications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"55109-3"}]}
.... 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 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:complications_section
Nested Section
... section I1..1BackboneElementProcedure Description 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..1CodeableConceptProcedure description
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]}
.... 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:procedure_description_section
Nested Section
... section I1..1BackboneElementProcedure Indications 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..1CodeableConceptProcedure indications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59768-2"}]}
.... 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:procedure_indications_section
Nested Section
... section I1..1BackboneElementPostprocedure 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..1CodeableConceptPostprocedure diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59769-0"}]}
.... 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:postprocedure_diagnosis_section
Nested Section
... section I0..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/or 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 I0..1BackboneElementAssessment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_section
Nested Section
... section I0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_and_plan_section
Nested Section
... section I0..1BackboneElementAnesthesia 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..1CodeableConceptAnesthesia
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59774-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core MedicationStatement Profile | 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:anesthesia_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..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..1BackboneElementMedical (General) 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..1CodeableConceptMedical (general) history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11329-0"}]}
.... 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:medical_history_section
Nested Section
... section I0..1BackboneElementMedications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core MedicationStatement Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medications_section
Nested Section
... section I0..1BackboneElementMedications Administered 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 administered
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]}
.... 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 MedicationStatement Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medications_administered_section
Nested Section
... section I0..1BackboneElementPhysical Exam Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:physical_exam_section
Nested Section
... section I0..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..1BackboneElementPlanned Procedure 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..1CodeableConceptPlanned procedure
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59772-4"}]}
.... text I1..1Narrativetext
.... 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:planned_procedure_section
Nested Section
... section I0..1BackboneElementProcedure Disposition 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..1CodeableConceptProcedure disposition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59775-7"}]}
.... 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:procedure_disposition_section
Nested Section
... section I0..1BackboneElementProcedure Estimated Blood Loss 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..1CodeableConceptProcedure estimated blood loss
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59770-8"}]}
.... 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:procedure_estimated_blood_loss_section
Nested Section
... section I0..1BackboneElementProcedure Findings 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..1CodeableConceptProcedure findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59776-5"}]}
.... 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:procedure_findings_section
Nested Section
... section I0..1BackboneElementProcedure Implants 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..1CodeableConceptProcedure implants
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59771-6"}]}
.... 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:procedure_implants_section
Nested Section
... section I0..1BackboneElementProcedure Specimens Taken 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..1CodeableConceptProcedure specimens taken
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59773-2"}]}
.... 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:procedure_specimens_taken_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

doco Documentation for this format

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

Summary

Mandatory: 20 elements (72 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptProcedure Note
Binding: ProcedureNoteDocumentTypeCodes (required)
... event 1..*BackboneElementserviceEvent
.... period 1..1Periodperiod
..... start 1..1dateTimestart
..... end 1..1dateTimeend
... section BackboneElementSlice: Unordered, Open by value:code
... section 1..1BackboneElementComplications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptComplications
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"55109-3"}]}
.... 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 1..1BackboneElementProcedure Description Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure description
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementProcedure Indications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure indications
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59768-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 1..1BackboneElementPostprocedure Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPostprocedure diagnosis
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59769-0"}]}
.... 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..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and/or 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 0..1BackboneElementAssessment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core Condition (a.k.a Problem) Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..1BackboneElementAnesthesia Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAnesthesia
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59774-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile | US Core Procedure 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..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..1BackboneElementMedical (General) History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedical (general) history
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11329-0"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementMedications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementMedications Administered Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications administered
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(US Core MedicationStatement Profile)
... section 0..1BackboneElementPhysical Exam Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text 1..1Narrativetext
.... entry Reference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry 0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
... section 0..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..1BackboneElementPlanned Procedure Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlanned procedure
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59772-4"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Disposition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure disposition
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59775-7"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Estimated Blood Loss Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure estimated blood loss
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59770-8"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Findings Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59776-5"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Implants Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure implants
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59771-6"}]}
.... text 1..1NarrativeThis section contains only human readable content
... section 0..1BackboneElementProcedure Specimens Taken Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure specimens taken
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59773-2"}]}
.... text 1..1NarrativeThis section contains only human readable content
... 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.

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..1CodeableConceptProcedure Note
Binding: ProcedureNoteDocumentTypeCodes (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 ΣI1..*BackboneElementserviceEvent
.... 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 Σ1..1Periodperiod
..... id 0..1stringxml:id (or equivalent in JSON)
..... start ΣI1..1dateTimestart
..... end ΣI1..1dateTimeend
.... 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..1BackboneElementComplications 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..1CodeableConceptComplications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"55109-3"}]}
.... 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 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:complications_section
Nested Section
... section I1..1BackboneElementProcedure Description 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..1CodeableConceptProcedure description
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]}
.... 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:procedure_description_section
Nested Section
... section I1..1BackboneElementProcedure Indications 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..1CodeableConceptProcedure indications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59768-2"}]}
.... 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:procedure_indications_section
Nested Section
... section I1..1BackboneElementPostprocedure 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..1CodeableConceptPostprocedure diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59769-0"}]}
.... 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:postprocedure_diagnosis_section
Nested Section
... section I0..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/or 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 I0..1BackboneElementAssessment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
.... text I1..1NarrativeThis section contains only human readable content
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_section
Nested Section
... section I0..1BackboneElementAssessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)A reference to data that supports this section
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core Condition (a.k.a Problem) Profile | Observation | Communication)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:assessment_and_plan_section
Nested Section
... section I0..1BackboneElementAnesthesia 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..1CodeableConceptAnesthesia
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59774-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core MedicationStatement Profile | 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:anesthesia_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..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..1BackboneElementMedical (General) 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..1CodeableConceptMedical (general) history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11329-0"}]}
.... 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:medical_history_section
Nested Section
... section I0..1BackboneElementMedications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(US Core MedicationStatement Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medications_section
Nested Section
... section I0..1BackboneElementMedications Administered 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 administered
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]}
.... 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 MedicationStatement Profile)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:medications_administered_section
Nested Section
... section I0..1BackboneElementPhysical Exam Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
.... text I1..1Narrativetext
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry IReference(Resource)entry
Slice: Unordered, Open by profile:reference
.... entry I0..*Reference(Observation)This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section:physical_exam_section
Nested Section
... section I0..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..1BackboneElementPlanned Procedure 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..1CodeableConceptPlanned procedure
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59772-4"}]}
.... text I1..1Narrativetext
.... 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:planned_procedure_section
Nested Section
... section I0..1BackboneElementProcedure Disposition 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..1CodeableConceptProcedure disposition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59775-7"}]}
.... 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:procedure_disposition_section
Nested Section
... section I0..1BackboneElementProcedure Estimated Blood Loss 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..1CodeableConceptProcedure estimated blood loss
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59770-8"}]}
.... 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:procedure_estimated_blood_loss_section
Nested Section
... section I0..1BackboneElementProcedure Findings 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..1CodeableConceptProcedure findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59776-5"}]}
.... 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:procedure_findings_section
Nested Section
... section I0..1BackboneElementProcedure Implants 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..1CodeableConceptProcedure implants
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59771-6"}]}
.... 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:procedure_implants_section
Nested Section
... section I0..1BackboneElementProcedure Specimens Taken 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..1CodeableConceptProcedure specimens taken
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59773-2"}]}
.... 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:procedure_specimens_taken_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

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

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