Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) | |
section | BackboneElement | Slice: Unordered, Open by value:code | ||
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core AllergyIntolerance Profile) | ||
section | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and plan Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief complaint Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Required Pattern: {"coding":[{"system":"http://loinc.org","code":"69730-0"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Interventions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Interventions provided Required Pattern: {"coding":[{"system":"http://loinc.org","code":"62387-6"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core MedicationStatement Profile) | ||
section | 0..1 | BackboneElement | Nutrition Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Diet and nutrition Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61144-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Objective Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Objective Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61149-1"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical findings Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ProcedureRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section | 0..1 | BackboneElement | Problems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem list Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Condition (a.k.a Problem) Profile) | ||
section | 0..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(US Core Results Profile) | ||
section | 0..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of systems Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Subjective Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Subjective Required Pattern: {"coding":[{"system":"http://loinc.org","code":"61150-9"}]} | |
text | 1..1 | Narrative | This section contains only human readable content | |
section | 0..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital signs Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | Reference(Resource) | entry Slice: Unordered, Open by profile:reference | ||
entry | 0..* | Reference(VitalSigns) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
Documentation for this format |