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
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection | Version: 3.0.0 | |||
Draft as of 2024-05-18 | 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.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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-preop-dx: SHOULD contain Preoperative 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: 2.16.840.1.113883.10.20.22.2.34 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | Surgical operation note preoperative diagnosis Narrative | |
@code | 1..1 | cs | Required Pattern: 10219-4 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:act | |
entry:preopDiagnosis | 0..1 | Entry | ||
act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
Documentation for this format |
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')) |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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-preop-dx: SHOULD contain Preoperative 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: 2.16.840.1.113883.10.20.22.2.34 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | Surgical operation note preoperative diagnosis Narrative Binding: DocumentSectionType (example) | |
@code | 1..1 | cs | Required Pattern: 10219-4 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:act | |
entry:preopDiagnosis | 0..1 | Entry | ||
act | C | 1..1 | PreoperativeDiagnosis | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
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')) | |
should-text-ref-value | warning | Section.entry:preopDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
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 | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
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 |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) | |
should-text-ref-value | warning | Section.entry:preopDiagnosis.act | SHOULD 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:
Differential View
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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-preop-dx: SHOULD contain Preoperative 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: 2.16.840.1.113883.10.20.22.2.34 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | Surgical operation note preoperative diagnosis Narrative | |
@code | 1..1 | cs | Required Pattern: 10219-4 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:act | |
entry:preopDiagnosis | 0..1 | Entry | ||
act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
Documentation for this format |
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
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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-preop-dx: SHOULD contain Preoperative 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: 2.16.840.1.113883.10.20.22.2.34 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | Surgical operation note preoperative diagnosis Narrative Binding: DocumentSectionType (example) | |
@code | 1..1 | cs | Required Pattern: 10219-4 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ST | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:act | |
entry:preopDiagnosis | 0..1 | Entry | ||
act | C | 1..1 | PreoperativeDiagnosis | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
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')) | |
should-text-ref-value | warning | Section.entry:preopDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() |
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 | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
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 |
should-preop-dx | warning | Section | SHOULD contain Preoperative Diagnosis : entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis')) | |
should-text-ref-value | warning | Section.entry:preopDiagnosis.act | SHOULD 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: