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Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection | Version: 4.0.0 | |||
Draft as of 2025-06-20 | Computable Name: PreoperativeDiagnosisSection | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.34:2015-08-01 |
The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon's opinion, the diagnosis that will be confirmed during surgery.
Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:
Recommended Entries: PreoperativeDiagnosis
Usages:
Changes since version 3.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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C | 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) Constraints: should-preop-dx |
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1..* | II | Slice: Unordered, Open by value:root, value:extension | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.34 | |
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1..1 | st | Required Pattern: 2015-08-01 | |
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1..1 | CE | Surgical operation note preoperative diagnosis Narrative | |
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1..1 | cs | Required Pattern: 10219-4 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..* | Entry | Slice: Unordered, Open by profile:act | |
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0..1 | Entry | ||
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1..1 | PreoperativeDiagnosis | ||
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Id | Grade | Path(s) | Details | Requirements |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) |
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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.entry:preopDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
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 |
II-1 | error | Section.typeId, Section.entry:preopDiagnosis.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) |
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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.entry:preopDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
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 |
II-1 | error | Section.typeId, Section.entry:preopDiagnosis.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) |
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 Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
C | 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) Constraints: should-preop-dx |
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1..* | II | Slice: Unordered, Open by value:root, value:extension | |
![]() ![]() ![]() ![]() |
1..1 | II | ||
![]() ![]() ![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.34 | |
![]() ![]() ![]() ![]() ![]() |
1..1 | st | Required Pattern: 2015-08-01 | |
![]() ![]() ![]() |
1..1 | CE | Surgical operation note preoperative diagnosis Narrative | |
![]() ![]() ![]() ![]() |
1..1 | cs | Required Pattern: 10219-4 | |
![]() ![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() ![]() |
1..1 | ST | ||
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1..1 | xhtml | ||
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0..* | Entry | Slice: Unordered, Open by profile:act | |
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0..1 | Entry | ||
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1..1 | PreoperativeDiagnosis | ||
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Id | Grade | Path(s) | Details | Requirements |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) |
Key Elements View
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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.entry:preopDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
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 |
II-1 | error | Section.typeId, Section.entry:preopDiagnosis.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) |
Snapshot View
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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.entry:preopDiagnosis.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:preopDiagnosis.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
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 |
II-1 | error | Section.typeId, Section.entry:preopDiagnosis.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) |
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: