Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) | |
event | 1..* | BackboneElement | serviceEvent | |
period | 1..1 | Period | period | |
start | 1..1 | dateTime | start | |
end | 1..1 | dateTime | end | |
section | BackboneElement | Slice: Unordered, Open by value:code | ||
section | 1..1 | BackboneElement | Complications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Complications Required Pattern: {"coding":[{"system":"http://loinc.org","code":"55109-3"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | ||
section | 1..1 | BackboneElement | Procedure Description Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure description Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 1..1 | BackboneElement | Procedure Indications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure indications Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59768-2"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 1..1 | BackboneElement | Postprocedure Diagnosis Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Postprocedure diagnosis Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59769-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | ||
section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies and/or adverse reactions Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core AllergyIntolerance Profile) | ||
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and plan Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Anesthesia Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Anesthesia Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59774-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core MedicationStatement Profile | US Core Procedure Profile) | ||
section | 0..1 | BackboneElement | Chief 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..1 | string | title | |
code | 1..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46239-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Family History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10157-6"}]} | |
text | 1..1 | Narrative | text | |
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..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | ||
section | 0..1 | BackboneElement | History of Present Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Medical (General) History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Medical (general) history Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11329-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core MedicationStatement Profile) | ||
section | 0..1 | BackboneElement | Medications Administered Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Medications administered Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core MedicationStatement Profile) | ||
section | 0..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical findings Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of treatment Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ProcedureRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Planned Procedure Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Planned procedure Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59772-4"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Disposition Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure disposition Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59775-7"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure estimated blood loss Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59770-8"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Procedure Findings Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure findings Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59776-5"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Procedure Implants Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure implants Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59771-6"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Procedure Specimens Taken Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure specimens taken Required Pattern: {"coding":[{"system":"http://loinc.org","code":"59773-2"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Procedures Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of procedures Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Procedure Profile) | ||
section | 0..1 | BackboneElement | Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29299-5"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of systems Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Social History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social history Required Pattern: {"coding":[{"code":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
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. | |
Documentation for this format |