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: Social History Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection Version: 3.0.0
Draft as of 2024-05-18 Computable Name: SocialHistorySection
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2015-08-01

This section contains social history data that influence a patient’s physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header. Mental/behavioral health assessments such as PHQ-9 (Patient Health Questionnaire-9) for depression screening are captured in the Mental Status section.

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-smoking-status: SHOULD contain Smoking Status
... 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: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Social history Narrative
.... @code 1..1 cs Required Pattern: 29762-2
.... @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:socialHistory 0..* Entry
..... observation 1..1 SocialHistoryObservation Base for all types and resources
.... entry:pregnancyPregnancy 0..* Entry
..... observation 1..1 PregnancyObservation Base for all types and resources
.... entry:smokingStatus 0..* Entry
..... observation 1..1 SmokingStatus Base for all types and resources
.... entry:caregiver 0..* Entry
..... observation 1..1 CaregiverCharacteristics Base for all types and resources
.... entry:culteralReligious 0..* Entry
..... observation 1..1 CulturalandReligiousObservation Base for all types and resources
.... entry:homeCharacteristics 0..* Entry
..... observation 1..1 CharacteristicsofHomeEnvironment Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-smoking-statuswarningSectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
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-smoking-status: SHOULD contain Smoking Status
... 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: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Social history Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 29762-2
.... @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:socialHistory 0..* Entry
..... observation C 1..1 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
should-sh-author: SHOULD contain author
.... entry:pregnancyPregnancy 0..* Entry
..... observation C 1..1 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entry:smokingStatus 0..* Entry
..... observation C 1..1 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
.... entry:caregiver 0..* Entry
..... observation C 1..1 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entry:culteralReligious 0..* Entry
..... observation C 1..1 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entry:homeCharacteristics 0..* Entry
..... observation C 1..1 CharacteristicsofHomeEnvironment 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
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
coded-valueerrorSection.entry:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: 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-smoking-status: SHOULD contain Smoking Status
... @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: 2.16.840.1.113883.10.20.22.2.17
..... @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 Social history Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 29762-2
.... @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:socialHistory 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
should-sh-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:pregnancyPregnancy 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:smokingStatus 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:caregiver 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:culteralReligious 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:homeCharacteristics 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 CharacteristicsofHomeEnvironment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:socialHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:socialHistory.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:pregnancyPregnancy.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:pregnancyPregnancy.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:pregnancyPregnancy.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:smokingStatus.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:smokingStatus.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:smokingStatus.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:caregiver.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:caregiver.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:caregiver.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:culteralReligious.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:culteralReligious.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:culteralReligious.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:homeCharacteristics.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:homeCharacteristics.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:homeCharacteristics.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
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
coded-valueerrorSection.entry:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: value.exists()

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-smoking-status: SHOULD contain Smoking Status
... 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: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Social history Narrative
.... @code 1..1 cs Required Pattern: 29762-2
.... @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:socialHistory 0..* Entry
..... observation 1..1 SocialHistoryObservation Base for all types and resources
.... entry:pregnancyPregnancy 0..* Entry
..... observation 1..1 PregnancyObservation Base for all types and resources
.... entry:smokingStatus 0..* Entry
..... observation 1..1 SmokingStatus Base for all types and resources
.... entry:caregiver 0..* Entry
..... observation 1..1 CaregiverCharacteristics Base for all types and resources
.... entry:culteralReligious 0..* Entry
..... observation 1..1 CulturalandReligiousObservation Base for all types and resources
.... entry:homeCharacteristics 0..* Entry
..... observation 1..1 CharacteristicsofHomeEnvironment Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-smoking-statuswarningSectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))

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-smoking-status: SHOULD contain Smoking Status
... 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: 2.16.840.1.113883.10.20.22.2.17
..... @extension 1..1 st Required Pattern: 2015-08-01
... code 1..1 CE Social history Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 29762-2
.... @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:socialHistory 0..* Entry
..... observation C 1..1 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
should-sh-author: SHOULD contain author
.... entry:pregnancyPregnancy 0..* Entry
..... observation C 1..1 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entry:smokingStatus 0..* Entry
..... observation C 1..1 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
.... entry:caregiver 0..* Entry
..... observation C 1..1 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entry:culteralReligious 0..* Entry
..... observation C 1..1 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entry:homeCharacteristics 0..* Entry
..... observation C 1..1 CharacteristicsofHomeEnvironment 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
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
coded-valueerrorSection.entry:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: 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-smoking-status: SHOULD contain Smoking Status
... @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: 2.16.840.1.113883.10.20.22.2.17
..... @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 Social history Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 29762-2
.... @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:socialHistory 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
should-sh-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:pregnancyPregnancy 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:smokingStatus 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:caregiver 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:culteralReligious 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entry:homeCharacteristics 0..* 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 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 CharacteristicsofHomeEnvironment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:socialHistory.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:socialHistory.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:socialHistory.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:pregnancyPregnancy.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:pregnancyPregnancy.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:pregnancyPregnancy.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:smokingStatus.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:smokingStatus.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:smokingStatus.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:caregiver.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:caregiver.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:caregiver.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:culteralReligious.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:culteralReligious.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:culteralReligious.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.entry:homeCharacteristics.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:homeCharacteristics.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:homeCharacteristics.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
4515-8555errorSection.entry:socialHistory.observationIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
coded-valueerrorSection.entry:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-effectiveTimewarningSection.entry:pregnancyPregnancy.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-sh-authorwarningSection.entry:socialHistory.observationSHOULD contain author
: author.exists()
should-smoking-statuswarningSectionSHOULD contain Smoking Status
: entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus'))
should-text-ref-valuewarningSection.entry:socialHistory.observation, Section.entry:pregnancyPregnancy.observation, Section.entry:smokingStatus.observation, Section.entry:caregiver.observation, Section.entry:culteralReligious.observation, Section.entry:homeCharacteristics.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:socialHistory.observationSHOULD contain value
: value.exists()

 

Other representations of profile: CSV, Excel