Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. The current version which supersedes this version is 4.0.0. For a full list of available versions, see the Directory of published versions

Logical Model: Assessment Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection Version: 3.0.0
Draft as of 2024-05-18 Computable Name: AssessmentSection
Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.8

The Assessment Section (also referred to as “impression” or “diagnoses” outside of the context of CDA) represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The assessment may be a list of specific disease entities or a narrative block.

Usage:

Formal Views of Template Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.8
..... @extension 0..0
... code 1..1 CE Evaluation note
.... @code 1..1 cs Required Pattern: 51848-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.8
... code 1..1 CE Evaluation note
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 51848-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.8
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Evaluation note
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 51848-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... entry 0..* Entry
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

This structure is derived from Section

Summary

Mandatory: 8 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Section.templateId

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.8
..... @extension 0..0
... code 1..1 CE Evaluation note
.... @code 1..1 cs Required Pattern: 51848-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.8
... code 1..1 CE Evaluation note
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 51848-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... title 1..1 ST

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1 Section XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.8
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Evaluation note
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 51848-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... entry 0..* Entry
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

This structure is derived from Section

Summary

Mandatory: 8 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Section.templateId

 

Other representations of profile: CSV, Excel