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. For a full list of available versions, see the Directory of published versions
Draft as of 2024-05-18 |
Definitions for the OperativeNoteSurgicalProcedureSection logical model.
Guidance on how to interpret the contents of this table can be found here
0. Section | |
Logical Container | ClinicalDocument (CDA Class) |
Validation | Instance of this type are validated by templateId |
XML Format | In the XML format, this property has the namespace urn:hl7-org:v3 . |
2. Section.templateId | |
Control | 1..? |
Slicing | This element introduces a set of slices on Section.templateId . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
4. Section.templateId:section | |
Slice Name | section |
Control | 1..1 |
6. Section.templateId:section.root | |
Control | 1..? |
Pattern Value | 2.16.840.1.113883.10.20.7.14 |
8. Section.templateId:section.extension | |
Control | 0..0 |
10. Section.code | |
Short | Surgical operation note surgical procedure Narrative |
Control | 1..? |
12. Section.code.code | |
Control | 1..? |
Pattern Value | 10223-6 |
14. Section.code.codeSystem | |
Control | 1..? |
Pattern Value | 2.16.840.1.113883.6.1 |
16. Section.title | |
Control | 1..? |
18. Section.text | |
Short | There SHALL be text indicating the procedure performed (CONF:81-8054). |
Control | 1..? |
Guidance on how to interpret the contents of this table can be found here
0. Section | |
Definition | Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. Base definition for all types defined in FHIR type system. |
Short | Base for all types and resources |
Control | 10..1* |
Is Modifier | false |
Logical Container | ClinicalDocument (CDA Class) |
Validation | Instance of this type are validated by templateId |
XML Format | In the XML format, this property has the namespace urn:hl7-org:v3 . |
2. Section.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
Slicing | This element introduces a set of slices on Section.templateId . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
4. Section.templateId:section | |
Slice Name | section |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
6. Section.templateId:section.root | |
Definition | A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Root |
Pattern Value | 2.16.840.1.113883.10.20.7.14 |
8. Section.templateId:section.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 0..0 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Extension |
10. Section.code | |
Short | Surgical operation note surgical procedure Narrative |
Control | 1..1 |
Binding | For example codes, see DocumentSectionType (example to http://terminology.hl7.org/ValueSet/v3-DocumentSectionType ) |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
12. Section.code.code | |
Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
Control | 1..1 |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Code |
Pattern Value | 10223-6 |
14. Section.code.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Code System |
Pattern Value | 2.16.840.1.113883.6.1 |
16. Section.code.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..0 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CR |
Label | Qualifier |
18. Section.title | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
20. Section.text | |
Short | There SHALL be text indicating the procedure performed (CONF:81-8054). |
Control | 1..1 |
Type | xhtml |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | This property is represented as CDA Text in the XML. |
Guidance on how to interpret the contents of this table can be found here
0. Section | |
Definition | Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. |
Short | Base for all types and resources |
Control | 1..1 |
Is Modifier | false |
Logical Container | ClinicalDocument (CDA Class) |
Validation | Instance of this type are validated by templateId |
XML Format | In the XML format, this property has the namespace urn:hl7-org:v3 . |
2. Section.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
4. Section.realmCode | |
Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
6. Section.typeId | |
Definition | When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question. |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
8. Section.typeId.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
10. Section.typeId.assigningAuthorityName | |
Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Assigning Authority Name |
12. Section.typeId.displayable | |
Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
Control | 0..1 |
Type | boolean(bl: Boolean) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Displayable |
14. Section.typeId.root | |
Definition | Identifies the type as an HL7 Registered model |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Root |
Fixed Value | 2.16.840.1.113883.1.3 |
16. Section.typeId.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 1..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Extension |
18. Section.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 1..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
Slicing | This element introduces a set of slices on Section.templateId . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
20. Section.templateId:section | |
Slice Name | section |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
22. Section.templateId:section.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
24. Section.templateId:section.assigningAuthorityName | |
Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Assigning Authority Name |
26. Section.templateId:section.displayable | |
Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
Control | 0..1 |
Type | boolean(bl: Boolean) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Displayable |
28. Section.templateId:section.root | |
Definition | A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Root |
Pattern Value | 2.16.840.1.113883.10.20.7.14 |
30. Section.templateId:section.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 0..0 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Extension |
32. Section.ID | |
Control | 0..1 |
Type | id(xs:ID) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
34. Section.classCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from ActClassRecordOrganizer (required to http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | DOCSECT |
36. Section.moodCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from CDAActMood (required to http://hl7.org/cda/stds/core/ValueSet/CDAActMood ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | EVN |
38. Section.id | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
40. Section.code | |
Short | Surgical operation note surgical procedure Narrative |
Control | 1..1 |
Binding | For example codes, see DocumentSectionType (example to http://terminology.hl7.org/ValueSet/v3-DocumentSectionType ) |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
42. Section.code.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
44. Section.code.code | |
Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
Control | 1..1 |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Code |
Pattern Value | 10223-6 |
46. Section.code.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Code System |
Pattern Value | 2.16.840.1.113883.6.1 |
48. Section.code.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Code System Name |
50. Section.code.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Code System Version |
52. Section.code.displayName | |
Definition | A name or title for the code, under which the sending system shows the code value to its users. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Display Name |
54. Section.code.sdtcValueSet | |
Definition | The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string(oid: ISO Object Identifier) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc .In the XML format, this property has the actual namevalueSet . |
56. Section.code.sdtcValueSetVersion | |
Definition | The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc .In the XML format, this property has the actual namevalueSetVersion . |
58. Section.code.originalText | |
Definition | The text or phrase used as the basis for the coding. |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ED |
Label | Original Text |
60. Section.code.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..0 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CR |
Label | Qualifier |
62. Section.code.translation | |
Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CD |
XML Format | The type of this property is determined using the " xsi:type attribute. |
Label | Translation |
64. Section.title | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/ST |
66. Section.text | |
Short | There SHALL be text indicating the procedure performed (CONF:81-8054). |
Control | 1..1 |
Type | xhtml |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | This property is represented as CDA Text in the XML. |
68. Section.confidentialityCode | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CE |
70. Section.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from AllLanguages (required to http://hl7.org/fhir/ValueSet/all-languages ) |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
72. Section.subject | |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Subject |
74. Section.author | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Author |
76. Section.informant | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Informant |
78. Section.entry | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Entry |
80. Section.component | |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot |
82. Section.component.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
84. Section.component.realmCode | |
Definition | When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/CS |
86. Section.component.typeId | |
Definition | When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question. |
Control | 0..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
88. Section.component.typeId.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from CDANullFlavor (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor ) |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Exceptional Value Detail |
90. Section.component.typeId.assigningAuthorityName | |
Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
Control | 0..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Assigning Authority Name |
92. Section.component.typeId.displayable | |
Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
Control | 0..1 |
Type | boolean(bl: Boolean) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Displayable |
94. Section.component.typeId.root | |
Definition | Identifies the type as an HL7 Registered model |
Control | 1..1 |
Type | string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Root |
Fixed Value | 2.16.840.1.113883.1.3 |
96. Section.component.typeId.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 1..1 |
Type | string(st: Character String) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Label | Extension |
98. Section.component.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 0..* |
Type | http://hl7.org/cda/stds/core/StructureDefinition/II |
100. Section.component.typeCode | |
Definition | Drawn from concept domain DocumentSectionType |
Control | 0..1 |
Type | code(cs: Coded Simple Value) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | COMP |
102. Section.component.contextConductionInd | |
Control | 0..1 |
Type | boolean(bl: Boolean) |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
XML Format | In the XML format, this property is represented as an attribute. |
Fixed Value | true |
104. Section.component.section | |
Control | 1..1 |
Type | http://hl7.org/cda/stds/core/StructureDefinition/Section |