Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v4.0.0: CCDA 4.0) 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

Logical Model: Physical Exam Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection Version: 4.0.0
Draft as of 2025-06-20 Computable Name: PhysicalExamSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.2.10:2015-08-01

The section includes direct observations made by a clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient's body.

It also includes observations made by the examining clinician using only inspection, palpation, auscultation, and percussion. It does not include laboratory or imaging findings.

The exam may be limited to pertinent body systems based on the patient's chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically.

The Physical Exam Section may contain multiple nested subsections.

Usages:

Changes since version 3.0.0:

  • No changes

    • Formal Views of Template Content

    Description of Template, Differentials, Snapshots and how the different presentations work.

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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: 2.16.840.1.113883.10.20.2.10
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... code 1..1 CE Physical findings Narrative
    .... @code 1..1 cs Required Pattern: 29545-1
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
    .... entry:longCareWound 0..* Entry
    ..... observation 1..1 LongitudinalCareWoundObservation
    ... component 0..* InfrastructureRoot
    .... section 1..1 Section
    ..... code 1..1 CE Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST
    ..... text 1..1 xhtml

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Section.component.section.codepreferredPhysicalExamType .
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 C 0..1 II Constraints: II-1
    .... @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: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: 2.16.840.1.113883.10.20.2.10
    ..... @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 Physical findings Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 29545-1
    .... @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:longCareWound 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 LongitudinalCareWoundObservation
    ..... 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 C 0..1 II Constraints: II-1
    ..... @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
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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
    ..... @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 Binding: Physical Exam Type . (preferred)
    ..... 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
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.component.section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.component.section.codepreferredPhysicalExamType .
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
    Section.component.section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 C 0..1 II Constraints: II-1
    .... @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: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: 2.16.840.1.113883.10.20.2.10
    ..... @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 Physical findings Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 29545-1
    .... @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:longCareWound 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 LongitudinalCareWoundObservation
    ..... 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 C 0..1 II Constraints: II-1
    ..... @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
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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
    ..... @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 Binding: Physical Exam Type . (preferred)
    ..... 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
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.component.section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.component.section.codepreferredPhysicalExamType .
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
    Section.component.section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()

    This structure is derived from Section

    Summary

    Mandatory: 9 elements(4 nested mandatory elements)

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Section.templateId
    • The element 1 is sliced based on the value of Section.entry

    Differential View

    This structure is derived from Section

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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: 2.16.840.1.113883.10.20.2.10
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... code 1..1 CE Physical findings Narrative
    .... @code 1..1 cs Required Pattern: 29545-1
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... title 1..1 ST
    ... Slices for entry 0..* Entry Slice: Unordered, Open by profile:observation
    .... entry:longCareWound 0..* Entry
    ..... observation 1..1 LongitudinalCareWoundObservation
    ... component 0..* InfrastructureRoot
    .... section 1..1 Section
    ..... code 1..1 CE Binding: Physical Exam Type . (preferred)
    ..... title 1..1 ST
    ..... text 1..1 xhtml

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Section.component.section.codepreferredPhysicalExamType .
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 C 0..1 II Constraints: II-1
    .... @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: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: 2.16.840.1.113883.10.20.2.10
    ..... @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 Physical findings Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 29545-1
    .... @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:longCareWound 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 LongitudinalCareWoundObservation
    ..... 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 C 0..1 II Constraints: II-1
    ..... @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
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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
    ..... @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 Binding: Physical Exam Type . (preferred)
    ..... 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
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.component.section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.component.section.codepreferredPhysicalExamType .
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
    Section.component.section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 C 0..1 II Constraints: II-1
    .... @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: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: 2.16.840.1.113883.10.20.2.10
    ..... @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 Physical findings Narrative
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 29545-1
    .... @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:longCareWound 0..* Entry
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 LongitudinalCareWoundObservation
    ..... 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 C 0..1 II Constraints: II-1
    ..... @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
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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
    ..... @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 Binding: Physical Exam Type . (preferred)
    ..... 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
    ..... entry 0..* Entry
    ..... component 0..* InfrastructureRoot
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... realmCode 0..* CS
    ...... typeId C 0..1 II Constraints: II-1
    ....... @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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.templateId:section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
    Section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.classCoderequiredFixed Value: DOCSECT
    http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
    Section.component.section.moodCoderequiredFixed Value: EVN
    http://hl7.org/cda/stds/core/ValueSet/CDAActMood
    Section.component.section.codepreferredPhysicalExamType .
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65
    Section.component.section.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Section.component.section.component.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorSection.typeId, Section.entry:longCareWound.typeId, Section.component.typeId, Section.component.section.typeId, Section.component.section.component.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()

    This structure is derived from Section

    Summary

    Mandatory: 9 elements(4 nested mandatory elements)

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Section.templateId
    • The element 1 is sliced based on the value of Section.entry

     

    Other representations of profile: CSV, Excel