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: Vital Signs Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: VitalSignsSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2015-08-01

The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure (including average blood pressure), heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.

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-vital-signs-org: SHALL contain at least one Vital Signs Organizer
... @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: 2.16.840.1.113883.10.20.22.2.4.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEVital Signs
.... @code 1..1csRequired Pattern: 8716-3
.... @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:organizer
.... entry:organizer 0..*Entry
..... organizer 1..1VitalSignsOrganizerBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-vital-signs-orgerrorSectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
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-vital-signs-org: SHALL contain at least one Vital Signs Organizer
... @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: 2.16.840.1.113883.10.20.22.2.4.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEVital Signs
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 8716-3
.... @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:organizer
.... entry:organizer 0..*Entry
..... organizer C1..1VitalSignsOrganizerBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-vital-signs-orgerrorSectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-authorwarningSection.entry:organizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:organizer.organizerSHOULD contain text/reference/@value
: sdtcText.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-vital-signs-org: SHALL contain at least one Vital Signs Organizer
... @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: 2.16.840.1.113883.10.20.22.2.4.1
..... @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..1CEVital Signs
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 8716-3
.... @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:organizer
.... entry:organizer 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 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer C1..1VitalSignsOrganizerBase for all types and resources
..... 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:organizer.nullFlavorrequiredCDANullFlavor
Section.entry:organizer.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:organizer.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-vital-signs-orgerrorSectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-authorwarningSection.entry:organizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:organizer.organizerSHOULD contain text/reference/@value
: sdtcText.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:organizer

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-vital-signs-org: SHALL contain at least one Vital Signs Organizer
... @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: 2.16.840.1.113883.10.20.22.2.4.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEVital Signs
.... @code 1..1csRequired Pattern: 8716-3
.... @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:organizer
.... entry:organizer 0..*Entry
..... organizer 1..1VitalSignsOrganizerBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-vital-signs-orgerrorSectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))

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-vital-signs-org: SHALL contain at least one Vital Signs Organizer
... @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: 2.16.840.1.113883.10.20.22.2.4.1
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEVital Signs
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 8716-3
.... @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:organizer
.... entry:organizer 0..*Entry
..... organizer C1..1VitalSignsOrganizerBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-vital-signs-orgerrorSectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-authorwarningSection.entry:organizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:organizer.organizerSHOULD contain text/reference/@value
: sdtcText.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-vital-signs-org: SHALL contain at least one Vital Signs Organizer
... @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: 2.16.840.1.113883.10.20.22.2.4.1
..... @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..1CEVital Signs
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 8716-3
.... @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:organizer
.... entry:organizer 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 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer C1..1VitalSignsOrganizerBase for all types and resources
..... 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:organizer.nullFlavorrequiredCDANullFlavor
Section.entry:organizer.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:organizer.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-vital-signs-orgerrorSectionSHALL contain at least one Vital Signs Organizer
: nullFlavor.exists() or entry.where(organizer.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsOrganizer'))
should-authorwarningSection.entry:organizer.organizerSHOULD contain author
: author.exists()
should-sdtctext-ref-valuewarningSection.entry:organizer.organizerSHOULD contain text/reference/@value
: sdtcText.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:organizer

 

Other representations of profile: CSV, Excel