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. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis | Version: 3.0.0 | |||
Draft as of 2024-05-18 | Computable Name: PostprocedureDiagnosis | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.51:2015-08-01 |
This template represents the diagnosis or diagnoses discovered or confirmed during the procedure. They may be the same as preprocedure diagnoses or indications.
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:postprocedure-dx | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
@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: 59769-0 | |
@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:postprocedure-dx | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
@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: 59769-0 | |
@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: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJhttp://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 | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.templateId:postprocedure-dx.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJhttp://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:postprocedure-dx | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
@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: 59769-0 | |
@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:postprocedure-dx | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.51 | |
@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: 59769-0 | |
@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: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJhttp://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 | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.templateId:postprocedure-dx.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Act.entryRelationship:problemObservation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.entryRelationship:problemObservation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Act.entryRelationship:problemObservation.typeCode | required | Fixed Value: SUBJhttp://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: