Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

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

Logical Model: Postprocedure Diagnosis Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosisSection Version: 3.0.0
Draft as of 2024-05-18 Computable Name: PostprocedureDiagnosisSection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.36:2015-08-01

The Postprocedure Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the procedure. Often it is the same as the preprocedure diagnosis or indication.

Usage:

Formal Views of Template Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 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)
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.36
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Postprocedure diagnosis Narrative
.... @code 1..1 cs Required Pattern: 59769-0
.... @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:act
.... entry:postopDiagnosis 0..1 Entry
..... act 1..1 PostprocedureDiagnosis Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-post-procedure-dxwarningSectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 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)
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.36
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Postprocedure diagnosis Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 59769-0
.... @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:act
.... entry:postopDiagnosis 0..1 Entry
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-post-procedure-dxwarningSectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
should-text-ref-valuewarningSection.entry:postopDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 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)
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.36
..... @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 Postprocedure diagnosis Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59769-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:act
.... entry:postopDiagnosis 0..1 Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

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.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
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:postopDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:postopDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:postopDiagnosis.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

Constraints

IdGradePath(s)DetailsRequirements
should-post-procedure-dxwarningSectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
should-text-ref-valuewarningSection.entry:postopDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()

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:

  • 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 & Constraintsdoco
.. Section 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)
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.36
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Postprocedure diagnosis Narrative
.... @code 1..1 cs Required Pattern: 59769-0
.... @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:act
.... entry:postopDiagnosis 0..1 Entry
..... act 1..1 PostprocedureDiagnosis Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-post-procedure-dxwarningSectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 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)
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.36
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Postprocedure diagnosis Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 59769-0
.... @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:act
.... entry:postopDiagnosis 0..1 Entry
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
should-post-procedure-dxwarningSectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
should-text-ref-valuewarningSection.entry:postopDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 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)
should-post-procedure-dx: SHOULD contain Postprocedure Diagnosis
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:section 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.36
..... @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 Postprocedure diagnosis Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 59769-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry Slice: Unordered, Open by profile:act
.... entry:postopDiagnosis 0..1 Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

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.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
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:postopDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:postopDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:postopDiagnosis.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

Constraints

IdGradePath(s)DetailsRequirements
should-post-procedure-dxwarningSectionSHOULD contain Postprocedure Diagnosis
: entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis'))
should-text-ref-valuewarningSection.entry:postopDiagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()

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:

  • 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