Consolidated CDA
3.0.0-ballot - ballot
Consolidated CDA
3.0.0-ballot - ballot
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: PostprocedureDiagnosis | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.51:2015-08-01 | ||||
This template represents the diagnosis or diagnoses discovered or confirmed during the procedure. They may be the same as preprocedure diagnoses or indications.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:postprocedure-dx | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
  @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
 @classCode | 1..1 | cs | Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| code | 1..1 | CD | ||
| @code | 1..1 | cs | Required Pattern: 59769-0 | |
 @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
 Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
 observation | 1..1 | ProblemObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:postprocedure-dx | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| @classCode | 1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| code | 1..1 | CD | Binding: v3 Code System ActCode (example) | |
| @code | 1..1 | cs | Required Pattern: 59769-0 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| observation | C | 1..1 | ProblemObservation | Base for all types and resources |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Path | Conformance | ValueSet / Code |
| Act.nullFlavor | required | CDANullFlavor |
| Act.typeId.nullFlavor | required | CDANullFlavor |
| Act.templateId:postprocedure-dx.nullFlavor | required | CDANullFlavor |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.code.nullFlavor | required | CDANullFlavor |
| Act.text.nullFlavor | required | CDANullFlavor |
| Act.text.compression | required | CDACompressionAlgorithm |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Act.text.mediaType | example | MediaType |
| Act.text.representation | required | BinaryDataEncoding |
| Act.statusCode | required | ActStatus |
| Act.priorityCode | example | ActPriority |
| Act.languageCode | required | AllLanguages |
| Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 9 elements
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:postprocedure-dx | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| @classCode | 1..1 | cs | Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| code | 1..1 | CD | ||
| @code | 1..1 | cs | Required Pattern: 59769-0 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:postprocedure-dx | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| @classCode | 1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode | 1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| code | 1..1 | CD | Binding: v3 Code System ActCode (example) | |
| @code | 1..1 | cs | Required Pattern: 59769-0 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:problemObservation | 1..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| observation | C | 1..1 | ProblemObservation | Base for all types and resources |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Path | Conformance | ValueSet / Code |
| Act.nullFlavor | required | CDANullFlavor |
| Act.typeId.nullFlavor | required | CDANullFlavor |
| Act.templateId:postprocedure-dx.nullFlavor | required | CDANullFlavor |
| Act.classCode | required | Fixed Value: ACT |
| Act.moodCode | required | Fixed Value: EVN |
| Act.code | example | ActCode |
| Act.code.nullFlavor | required | CDANullFlavor |
| Act.text.nullFlavor | required | CDANullFlavor |
| Act.text.compression | required | CDACompressionAlgorithm |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Act.text.mediaType | example | MediaType |
| Act.text.representation | required | BinaryDataEncoding |
| Act.statusCode | required | ActStatus |
| Act.priorityCode | example | ActPriority |
| Act.languageCode | required | AllLanguages |
| Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:problemObservation.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 9 elements
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-21
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