Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Encounters Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/EncountersSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: EncountersSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.22.1:2015-08-01

This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility (exercising independent judgment) for assessing and treating the patient at a given contact. This section may contain all encounters for the time period being summarized, but should include notable encounters. NOTE: Since the EncounterActivity entry template has a moodCode of EVN, it is not possible to use it for planned encounters. The PlannedEncounter entry template should be used if future encounters are being included in this section.

Usage:

Formal Views of Profile Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-encounter-activity: SHALL contain at least one Encounter Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.22.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEEncounters
.... @code 1..1csRequired Pattern: 46240-8
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:encounter
.... entry:encounter 0..*Entry
..... encounter 1..1EncounterActivityBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-encounter-activityerrorSectionSHALL contain at least one Encounter Activity
: nullFlavor.exists() or entry.where(encounter.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-encounter-activity: SHALL contain at least one Encounter Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.22.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEEncounters
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 46240-8
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:encounter
.... entry:encounter 0..*Entry
..... encounter C1..1EncounterActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-encounter-activityerrorSectionSHALL contain at least one Encounter Activity
: nullFlavor.exists() or entry.where(encounter.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity'))
should-text-ref-valuewarningSection.entry:encounter.encounterSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-encounter-activity: SHALL contain at least one Encounter Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.22.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEEncounters
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 46240-8
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:encounter
.... entry:encounter 0..*Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter C1..1EncounterActivityBase for all types and resources
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:encounter.nullFlavorrequiredCDANullFlavor
Section.entry:encounter.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:encounter.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-encounter-activityerrorSectionSHALL contain at least one Encounter Activity
: nullFlavor.exists() or entry.where(encounter.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity'))
should-text-ref-valuewarningSection.entry:encounter.encounterSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of profile:encounter

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-encounter-activity: SHALL contain at least one Encounter Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.22.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEEncounters
.... @code 1..1csRequired Pattern: 46240-8
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:encounter
.... entry:encounter 0..*Entry
..... encounter 1..1EncounterActivityBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-encounter-activityerrorSectionSHALL contain at least one Encounter Activity
: nullFlavor.exists() or entry.where(encounter.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity'))

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-encounter-activity: SHALL contain at least one Encounter Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.22.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEEncounters
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 46240-8
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:encounter
.... entry:encounter 0..*Entry
..... encounter C1..1EncounterActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-encounter-activityerrorSectionSHALL contain at least one Encounter Activity
: nullFlavor.exists() or entry.where(encounter.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity'))
should-text-ref-valuewarningSection.entry:encounter.encounterSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-encounter-activity: SHALL contain at least one Encounter Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.22.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEEncounters
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 46240-8
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:encounter
.... entry:encounter 0..*Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter C1..1EncounterActivityBase for all types and resources
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:encounter.nullFlavorrequiredCDANullFlavor
Section.entry:encounter.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:encounter.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-encounter-activityerrorSectionSHALL contain at least one Encounter Activity
: nullFlavor.exists() or entry.where(encounter.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity'))
should-text-ref-valuewarningSection.entry:encounter.encounterSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of profile:encounter

 

Other representations of profile: CSV, Excel