Consolidated CDA (C-CDA)
3.0.0 - STU3
Consolidated CDA (C-CDA)
3.0.0 - STU3
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/PastMedicalHistory | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: PastMedicalHistory | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.20:2015-08-01 | ||||
This section contains a record of the patient’s past complaints, problems, and diagnoses. It contains data from the patient’s past up to the patient’s current complaint or reason for seeking medical care.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Section |
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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:section |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.20 | |
  @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | History of Past illness Narrative | |
 @code |
1..1 | cs | Required Pattern: 11348-0 | |
 @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
 Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation | |
| entry:problem |
0..* | Entry | ||
  observation |
1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). | |
| effectiveTime |
C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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, value:extension | |
| templateId:section |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.20 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | History of Past illness Narrative Binding: DocumentSectionType (example) | |
| @code |
1..1 | cs | Required Pattern: 11348-0 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation | |
| entry:problem |
0..* | Entry | ||
| observation |
C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:problem-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Binding: Problem Type (preferred) | |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high |
| low |
1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| value |
1..1 | CD | (USCDI) SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |
 entryRelationship:age |
0..1 | EntryRelationship | ||
 @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:prognosis |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:priority |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| entryRelationship:status |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:reference |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:assessment |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:dateOfDiagnosis |
0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act |
C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Section.entry:problem.observation.code | preferred | ProblemTypehttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
| Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
| Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
| should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 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 | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| 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: 2.16.840.1.113883.10.20.22.2.20 | |||||||
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |||||||
| @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 | History of Past illness Narrative Binding: DocumentSectionType (example) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Required Pattern: 11348-0 | |||||||
| @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 | ||||||||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation | |||||||
| entry:problem |
0..* | Entry | ||||||||
| @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 | Binding: x_ActRelationshipEntry (required) | |||||||
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| @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 | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs |
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: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd |
0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | Binding: Problem Type (preferred) | |||||||
| derivationExpr |
0..1 | ST | ||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
| @integrityCheck |
0..1 | bin | ||||||||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language |
0..1 | cs | ||||||||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |||||||
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| 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 | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| @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) | |||||||
| effectiveTime |
C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |||||||
| low |
1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| center |
0..1 | TS | ||||||||
| width |
0..1 | PQ | ||||||||
| high |
0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber |
0..1 | IVL_INT | ||||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||
| value |
1..1 | CD | (USCDI) SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| @codeSystem |
0..1 | oid, uuid, ruid | ||||||||
| @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 | ||||||||
| qualifier |
0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| translation |
0..* | CD | ||||||||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode |
0..* | CD | ||||||||
| subject |
0..1 | Subject | ||||||||
| specimen |
0..* | Specimen | ||||||||
| performer |
0..* | Performer2 | ||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant |
0..* | Informant | ||||||||
| participant |
0..* | Participant2 | ||||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |||||||
| entryRelationship:age |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:prognosis |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:priority |
0..* | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:status |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:reference |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:assessment |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:dateOfDiagnosis |
0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| reference |
0..* | Reference | ||||||||
| precondition |
0..* | Precondition | ||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange |
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 | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
| observationRange |
1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| 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 | ||||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:problem.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:problem.observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.templateId:problem-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Section.entry:problem.observation.code | preferred | ProblemTypehttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
| Section.entry:problem.observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Section.entry:problem.observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Section.entry:problem.observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Section.entry:problem.observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Section.entry:problem.observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| Section.entry:problem.observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Section.entry:problem.observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
| Section.entry:problem.observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.value.code | example | ||
| Section.entry:problem.observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Section.entry:problem.observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Section.entry:problem.observation.entryRelationship:age.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:priority.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
| should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Section.entry:problem.observation.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 Section
Summary
Mandatory: 9 elements(1 nested mandatory element)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Section |
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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:section |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.20 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | History of Past illness Narrative | |
| @code |
1..1 | cs | Required Pattern: 11348-0 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation | |
| entry:problem |
0..* | Entry | ||
| observation |
1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). | |
| effectiveTime |
C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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, value:extension | |
| templateId:section |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.20 | |
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |
| code |
1..1 | CE | History of Past illness Narrative Binding: DocumentSectionType (example) | |
| @code |
1..1 | cs | Required Pattern: 11348-0 | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title |
1..1 | ST | ||
| text |
1..1 | xhtml | ||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation | |
| entry:problem |
0..* | Entry | ||
| observation |
C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:problem-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Binding: Problem Type (preferred) | |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high |
| low |
1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| value |
1..1 | CD | (USCDI) SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |
| entryRelationship:age |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:prognosis |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:priority |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| entryRelationship:status |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:reference |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:assessment |
0..1 | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:dateOfDiagnosis |
0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act |
C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Section.entry:problem.observation.code | preferred | ProblemTypehttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
| Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
| Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
| should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 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 | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| 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: 2.16.840.1.113883.10.20.22.2.20 | |||||||
| @extension |
1..1 | st | Required Pattern: 2015-08-01 | |||||||
| @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 | History of Past illness Narrative Binding: DocumentSectionType (example) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Required Pattern: 11348-0 | |||||||
| @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 | ||||||||
| Slices for entry |
0..* | Entry | Slice: Unordered, Open by profile:observation | |||||||
| entry:problem |
0..* | Entry | ||||||||
| @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 | Binding: x_ActRelationshipEntry (required) | |||||||
| @contextConductionInd |
0..1 | bl | Fixed Value: true | |||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | ProblemObservation | Should contain an effectiveTime/high or and/or a Problem Status with value 73425007 (Inactive), 413322009 (Problem resolved), or 277022003 (Remission phase). should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| @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 | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs |
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: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd |
0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | Binding: Problem Type (preferred) | |||||||
| derivationExpr |
0..1 | ST | ||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
| @integrityCheck |
0..1 | bin | ||||||||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language |
0..1 | cs | ||||||||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |||||||
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| 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 | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| @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) | |||||||
| effectiveTime |
C | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. should-high: SHOULD contain high | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |||||||
| low |
1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| center |
0..1 | TS | ||||||||
| width |
0..1 | PQ | ||||||||
| high |
0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber |
0..1 | IVL_INT | ||||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||
| value |
1..1 | CD | (USCDI) SDOH Problems/Health Concerns Binding: US Core Condition Codes (preferred) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| @codeSystem |
0..1 | oid, uuid, ruid | ||||||||
| @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 | ||||||||
| qualifier |
0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| translation |
0..* | CD | ||||||||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode |
0..* | CD | ||||||||
| subject |
0..1 | Subject | ||||||||
| specimen |
0..* | Specimen | ||||||||
| performer |
0..* | Performer2 | ||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant |
0..* | Informant | ||||||||
| participant |
0..* | Participant2 | ||||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act | |||||||
| entryRelationship:age |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AgeObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:prognosis |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | PrognosisObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:priority |
0..* | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:status |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | ProblemStatus | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:reference |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:assessment |
0..1 | EntryRelationship | ||||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:dateOfDiagnosis |
0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | DateOfDiagnosisAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| reference |
0..* | Reference | ||||||||
| precondition |
0..* | Precondition | ||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange |
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 | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
| observationRange |
1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| 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 | ||||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:problem.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.entry:problem.observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.templateId:problem-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Section.entry:problem.observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Section.entry:problem.observation.code | preferred | ProblemTypehttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1 | |
| Section.entry:problem.observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Section.entry:problem.observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Section.entry:problem.observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Section.entry:problem.observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Section.entry:problem.observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Section.entry:problem.observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| Section.entry:problem.observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Section.entry:problem.observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:problem.observation.value | preferred | USCoreConditionCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | |
| Section.entry:problem.observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.value.code | example | ||
| Section.entry:problem.observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Section.entry:problem.observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Section.entry:problem.observation.entryRelationship:age.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:priority.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:priority.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:status.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Section.entry:problem.observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:problem.observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Section.entry:problem.observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-high | warning | Section.entry:problem.observation.effectiveTime | SHOULD contain high : high.exists() | |
| should-text-ref-value | warning | Section.entry:problem.observation, Section.entry:problem.observation.entryRelationship:age.observation, Section.entry:problem.observation.entryRelationship:prognosis.observation, Section.entry:problem.observation.entryRelationship:priority.observation, Section.entry:problem.observation.entryRelationship:status.observation, Section.entry:problem.observation.entryRelationship:reference.act, Section.entry:problem.observation.entryRelationship:assessment.observation, Section.entry:problem.observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Section.entry:problem.observation.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 Section
Summary
Mandatory: 9 elements(1 nested mandatory element)
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 based on FHIR 5.0.0. Generated 2024-05-18
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