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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HospitalAdmissionDiagnosis | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: HospitalAdmissionDiagnosis | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.34:2015-08-01 | ||||
This template represents problems or diagnoses identified by the clinician at the time of the patient’s admission.
This Hospital Admission Diagnosis act may contain more than one Problem Observation to represent multiple diagnoses for a Hospital Admission.
Usage:
Description of Template, 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 Instance 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:hospital-admission-dx | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.34 | |
|      @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: 46241-6 | |
|     @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 Instance 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:hospital-admission-dx | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.34 | |
|      @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: 46241-6 | |
|     @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 should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | 
|  Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI | 
| Act.classCode | required | Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCode http://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | 
| 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 | URI | 
| Act.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:hospital-admission-dx.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCode http://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaType http://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.priorityCode | example | ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | 
| 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: 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 Instance 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:hospital-admission-dx | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.34 | |
|      @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: 46241-6 | |
|     @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 Instance 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:hospital-admission-dx | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.34 | |
|      @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: 46241-6 | |
|     @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 should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | 
|  Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI | 
| Act.classCode | required | Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCode http://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | 
| 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 | URI | 
| Act.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:hospital-admission-dx.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACT http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCode http://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaType http://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.priorityCode | example | ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJ http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | 
| 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: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: