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: ProcedureSpecimensTakenSection - Detailed Descriptions

Draft as of 2024-05-18

Definitions for the ProcedureSpecimensTakenSection logical model.

Guidance on how to interpret the contents of this table can be found here

0. Section
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. Section.templateId
Control1..?
SlicingThis element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • 4. Section.templateId:section
    Slice Namesection
    Control1..1
    6. Section.templateId:section.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.2.31
    8. Section.templateId:section.extension
    Control0..0
    10. Section.code
    ShortProcedure specimens taken Narrative
    Control1..?
    12. Section.code.code
    Control1..?
    Pattern Value59773-2
    14. Section.code.codeSystem
    Control1..?
    Pattern Value2.16.840.1.113883.6.1
    16. Section.title
    Control1..?
    18. Section.text
    ShortThe Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
    Control1..?

    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.

    ShortBase for all types and resources
    Control10..1*
    Is Modifierfalse
    Logical ContainerClinicalDocument (CDA Class)
    ValidationInstance of this type are validated by templateId
    XML FormatIn 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

    Control1..*
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
    SlicingThis element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ root
    • 4. Section.templateId:section
      Slice Namesection
      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

      Control1..1
      Typehttp://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.

      Control1..1
      Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelRoot
      Pattern Value2.16.840.1.113883.10.20.22.2.31
      8. Section.templateId:section.extension
      Definition

      A character string as a unique identifier within the scope of the identifier root.

      Control0..0
      Typestring(st: Character String)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelExtension
      10. Section.code
      ShortProcedure specimens taken Narrative
      Control1..1
      BindingFor example codes, see DocumentSectionType
      (example to http://terminology.hl7.org/ValueSet/v3-DocumentSectionType)
      Typehttp://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.

      Control1..1
      Typecode(cs: Coded Simple Value)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelCode
      Pattern Value59773-2
      14. Section.code.codeSystem
      Definition

      Specifies the code system that defines the code.

      Control1..1
      Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelCode System
      Pattern Value2.16.840.1.113883.6.1
      16. Section.code.qualifier
      Definition

      Specifies additional codes that increase the specificity of the the primary code.

      Control0..0
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
      LabelQualifier
      18. Section.title
      Control1..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
      20. Section.text
      ShortThe Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
      Control1..1
      Typexhtml
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatThis 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.

      ShortBase for all types and resources
      Control1..1
      Is Modifierfalse
      Logical ContainerClinicalDocument (CDA Class)
      ValidationInstance of this type are validated by templateId
      XML FormatIn 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.

      Control0..1
      BindingThe codes SHALL be taken from CDANullFlavor
      (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
      Typecode(cs: Coded Simple Value)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelExceptional 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

      Control0..*
      Typehttp://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.

      Control0..1
      Typehttp://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.

      Control0..1
      BindingThe codes SHALL be taken from CDANullFlavor
      (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
      Typecode(cs: Coded Simple Value)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelExceptional 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.

      Control0..1
      Typestring(st: Character String)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelAssigning 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).

      Control0..1
      Typeboolean(bl: Boolean)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelDisplayable
      14. Section.typeId.root
      Definition

      Identifies the type as an HL7 Registered model

      Control1..1
      Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelRoot
      Fixed Value2.16.840.1.113883.1.3
      16. Section.typeId.extension
      Definition

      A character string as a unique identifier within the scope of the identifier root.

      Control1..1
      Typestring(st: Character String)
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      XML FormatIn the XML format, this property is represented as an attribute.
      LabelExtension
      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

      Control1..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
      SlicingThis element introduces a set of slices on Section.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ root
      • 20. Section.templateId:section
        Slice Namesection
        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

        Control1..1
        Typehttp://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.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional 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.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelAssigning 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).

        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelDisplayable
        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.

        Control1..1
        Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelRoot
        Pattern Value2.16.840.1.113883.10.20.22.2.31
        30. Section.templateId:section.extension
        Definition

        A character string as a unique identifier within the scope of the identifier root.

        Control0..0
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExtension
        32. Section.ID
        Control0..1
        Typeid(xs:ID)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        34. Section.classCode
        Control0..1
        BindingThe codes SHALL be taken from ActClassRecordOrganizer
        (required to http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Fixed ValueDOCSECT
        36. Section.moodCode
        Control0..1
        BindingThe codes SHALL be taken from CDAActMood
        (required to http://hl7.org/cda/stds/core/ValueSet/CDAActMood)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Fixed ValueEVN
        38. Section.id
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
        40. Section.code
        ShortProcedure specimens taken Narrative
        Control1..1
        BindingFor example codes, see DocumentSectionType
        (example to http://terminology.hl7.org/ValueSet/v3-DocumentSectionType)
        Typehttp://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.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional 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.

        Control1..1
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelCode
        Pattern Value59773-2
        46. Section.code.codeSystem
        Definition

        Specifies the code system that defines the code.

        Control1..1
        Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelCode System
        Pattern Value2.16.840.1.113883.6.1
        48. Section.code.codeSystemName
        Definition

        The common name of the coding system.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelCode System Name
        50. Section.code.codeSystemVersion
        Definition

        If applicable, a version descriptor defined specifically for the given code system.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelCode 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.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelDisplay 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.

        Control0..1
        Typestring(oid: ISO Object Identifier)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn 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.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn 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.

        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
        LabelOriginal Text
        60. Section.code.qualifier
        Definition

        Specifies additional codes that increase the specificity of the the primary code.

        Control0..0
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
        LabelQualifier
        62. Section.code.translation
        Definition

        A set of other concept descriptors that translate this concept descriptor into other code systems.

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
        XML FormatThe type of this property is determined using the " xsi:typeattribute.
        LabelTranslation
        64. Section.title
        Control1..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
        66. Section.text
        ShortThe Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
        Control1..1
        Typexhtml
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatThis property is represented as CDA Text in the XML.
        68. Section.confidentialityCode
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
        70. Section.languageCode
        Control0..1
        BindingThe codes SHALL be taken from AllLanguages
        (required to http://hl7.org/fhir/ValueSet/all-languages)
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
        72. Section.subject
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Subject
        74. Section.author
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
        76. Section.informant
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
        78. Section.entry
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Entry
        80. Section.component
        Control0..*
        Typehttp://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.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional 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

        Control0..*
        Typehttp://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.

        Control0..1
        Typehttp://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.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional 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.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelAssigning 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).

        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelDisplayable
        94. Section.component.typeId.root
        Definition

        Identifies the type as an HL7 Registered model

        Control1..1
        Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelRoot
        Fixed Value2.16.840.1.113883.1.3
        96. Section.component.typeId.extension
        Definition

        A character string as a unique identifier within the scope of the identifier root.

        Control1..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExtension
        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

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
        100. Section.component.typeCode
        Definition

        Drawn from concept domain DocumentSectionType

        Control0..1
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Fixed ValueCOMP
        102. Section.component.contextConductionInd
        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Fixed Valuetrue
        104. Section.component.section
        Control1..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section