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: Social History Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: SocialHistorySection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2015-08-01

This section contains social history data that influence a patient’s physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header.

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)
should-smoking-status: SHOULD contain Smoking Status - Meaningful Use
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CESocial History
.... @code 1..1csRequired Pattern: 29762-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:socialHistory 0..*Entry
..... observation 1..1SocialHistoryObservationBase for all types and resources
.... entry:pregnancyPregnancy 0..*Entry
..... observation 1..1PregnancyObservationBase for all types and resources
.... entry:smokingStatus 0..*Entry
..... observation 1..1SmokingStatusMeaningfulUseBase for all types and resources
.... entry:tobaccoUse 0..*Entry
..... observation 1..1TobaccoUseBase for all types and resources
.... entry:caregiver 0..*Entry
..... observation 1..1CaregiverCharacteristicsBase for all types and resources
.... entry:culteralReligious 0..*Entry
..... observation 1..1CulturalandReligiousObservationBase for all types and resources
.... entry:homeCharacteristics 0..*Entry
..... observation 1..1CharacteristicsofHomeEnvironmentBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-smoking-statuswarningSectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
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)
should-smoking-status: SHOULD contain Smoking Status - Meaningful Use
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CESocial History
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 29762-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:socialHistory 0..*Entry
..... observation C1..1SocialHistoryObservationBase for all types and resources
.... entry:pregnancyPregnancy 0..*Entry
..... observation C1..1PregnancyObservationBase for all types and resources
.... entry:smokingStatus 0..*Entry
..... observation C1..1SmokingStatusMeaningfulUseBase for all types and resources
.... entry:tobaccoUse 0..*Entry
..... observation C1..1TobaccoUseBase for all types and resources
.... entry:caregiver 0..*Entry
..... observation C1..1CaregiverCharacteristicsBase for all types and resources
.... entry:culteralReligious 0..*Entry
..... observation C1..1CulturalandReligiousObservationBase for all types and resources
.... entry:homeCharacteristics 0..*Entry
..... observation C1..1CharacteristicsofHomeEnvironmentBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
should-authorwarningSection.entry:smokingStatus.observation, Section.entry:tobaccoUse.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:tobaccoUse.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: 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)
should-smoking-status: SHOULD contain Smoking Status - Meaningful Use
... @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:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.17
..... @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..1CESocial History
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 29762-2
.... @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..*EntrySlice: Unordered, Open by profile:observation
.... entry:socialHistory 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 0..1Encounter
..... observation C1..1SocialHistoryObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:pregnancyPregnancy 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 0..1Encounter
..... observation C1..1PregnancyObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:smokingStatus 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 0..1Encounter
..... observation C1..1SmokingStatusMeaningfulUseBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:tobaccoUse 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 0..1Encounter
..... observation C1..1TobaccoUseBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:caregiver 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 0..1Encounter
..... observation C1..1CaregiverCharacteristicsBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:culteralReligious 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 0..1Encounter
..... observation C1..1CulturalandReligiousObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:homeCharacteristics 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 0..1Encounter
..... observation C1..1CharacteristicsofHomeEnvironmentBase for all types and resources
..... 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:socialHistory.nullFlavorrequiredCDANullFlavor
Section.entry:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:socialHistory.typeCoderequiredXActRelationshipEntry
Section.entry:pregnancyPregnancy.nullFlavorrequiredCDANullFlavor
Section.entry:pregnancyPregnancy.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:pregnancyPregnancy.typeCoderequiredXActRelationshipEntry
Section.entry:smokingStatus.nullFlavorrequiredCDANullFlavor
Section.entry:smokingStatus.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:smokingStatus.typeCoderequiredXActRelationshipEntry
Section.entry:tobaccoUse.nullFlavorrequiredCDANullFlavor
Section.entry:tobaccoUse.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:tobaccoUse.typeCoderequiredXActRelationshipEntry
Section.entry:caregiver.nullFlavorrequiredCDANullFlavor
Section.entry:caregiver.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:caregiver.typeCoderequiredXActRelationshipEntry
Section.entry:culteralReligious.nullFlavorrequiredCDANullFlavor
Section.entry:culteralReligious.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:culteralReligious.typeCoderequiredXActRelationshipEntry
Section.entry:homeCharacteristics.nullFlavorrequiredCDANullFlavor
Section.entry:homeCharacteristics.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:homeCharacteristics.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
should-authorwarningSection.entry:smokingStatus.observation, Section.entry:tobaccoUse.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:tobaccoUse.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: value.exists()

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)
should-smoking-status: SHOULD contain Smoking Status - Meaningful Use
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CESocial History
.... @code 1..1csRequired Pattern: 29762-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:socialHistory 0..*Entry
..... observation 1..1SocialHistoryObservationBase for all types and resources
.... entry:pregnancyPregnancy 0..*Entry
..... observation 1..1PregnancyObservationBase for all types and resources
.... entry:smokingStatus 0..*Entry
..... observation 1..1SmokingStatusMeaningfulUseBase for all types and resources
.... entry:tobaccoUse 0..*Entry
..... observation 1..1TobaccoUseBase for all types and resources
.... entry:caregiver 0..*Entry
..... observation 1..1CaregiverCharacteristicsBase for all types and resources
.... entry:culteralReligious 0..*Entry
..... observation 1..1CulturalandReligiousObservationBase for all types and resources
.... entry:homeCharacteristics 0..*Entry
..... observation 1..1CharacteristicsofHomeEnvironmentBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-smoking-statuswarningSectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))

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)
should-smoking-status: SHOULD contain Smoking Status - Meaningful Use
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CESocial History
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 29762-2
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:socialHistory 0..*Entry
..... observation C1..1SocialHistoryObservationBase for all types and resources
.... entry:pregnancyPregnancy 0..*Entry
..... observation C1..1PregnancyObservationBase for all types and resources
.... entry:smokingStatus 0..*Entry
..... observation C1..1SmokingStatusMeaningfulUseBase for all types and resources
.... entry:tobaccoUse 0..*Entry
..... observation C1..1TobaccoUseBase for all types and resources
.... entry:caregiver 0..*Entry
..... observation C1..1CaregiverCharacteristicsBase for all types and resources
.... entry:culteralReligious 0..*Entry
..... observation C1..1CulturalandReligiousObservationBase for all types and resources
.... entry:homeCharacteristics 0..*Entry
..... observation C1..1CharacteristicsofHomeEnvironmentBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
should-authorwarningSection.entry:smokingStatus.observation, Section.entry:tobaccoUse.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:tobaccoUse.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: 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)
should-smoking-status: SHOULD contain Smoking Status - Meaningful Use
... @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:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.17
..... @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..1CESocial History
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 29762-2
.... @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..*EntrySlice: Unordered, Open by profile:observation
.... entry:socialHistory 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 0..1Encounter
..... observation C1..1SocialHistoryObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:pregnancyPregnancy 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 0..1Encounter
..... observation C1..1PregnancyObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:smokingStatus 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 0..1Encounter
..... observation C1..1SmokingStatusMeaningfulUseBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:tobaccoUse 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 0..1Encounter
..... observation C1..1TobaccoUseBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:caregiver 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 0..1Encounter
..... observation C1..1CaregiverCharacteristicsBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:culteralReligious 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 0..1Encounter
..... observation C1..1CulturalandReligiousObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:homeCharacteristics 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 0..1Encounter
..... observation C1..1CharacteristicsofHomeEnvironmentBase for all types and resources
..... 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:socialHistory.nullFlavorrequiredCDANullFlavor
Section.entry:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:socialHistory.typeCoderequiredXActRelationshipEntry
Section.entry:pregnancyPregnancy.nullFlavorrequiredCDANullFlavor
Section.entry:pregnancyPregnancy.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:pregnancyPregnancy.typeCoderequiredXActRelationshipEntry
Section.entry:smokingStatus.nullFlavorrequiredCDANullFlavor
Section.entry:smokingStatus.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:smokingStatus.typeCoderequiredXActRelationshipEntry
Section.entry:tobaccoUse.nullFlavorrequiredCDANullFlavor
Section.entry:tobaccoUse.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:tobaccoUse.typeCoderequiredXActRelationshipEntry
Section.entry:caregiver.nullFlavorrequiredCDANullFlavor
Section.entry:caregiver.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:caregiver.typeCoderequiredXActRelationshipEntry
Section.entry:culteralReligious.nullFlavorrequiredCDANullFlavor
Section.entry:culteralReligious.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:culteralReligious.typeCoderequiredXActRelationshipEntry
Section.entry:homeCharacteristics.nullFlavorrequiredCDANullFlavor
Section.entry:homeCharacteristics.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:homeCharacteristics.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
should-authorwarningSection.entry:smokingStatus.observation, Section.entry:tobaccoUse.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status - Meaningful Use
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatusMeaningfulUse'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:tobaccoUse.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: value.exists()

 

Other representations of profile: CSV, Excel