This page is part of the C-CDA on FHIR Implementation Guide (v1.6.0: STU 1 Ballot 1) based on FHIR v1.6.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions
The official URL for this profile is:
http://hl7.org/fhir/ccda/StructureDefinition/ccda-history-and-physical-composition
A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members. The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.
This profile was published on Thu Aug 11 21:16:47 AEST 2016 as a draft by Lantana Consulting Group.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
Example for: C-CDA on FHIR History and Physical.
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 41 elements (+33 nested mandatory elements)
Fixed Value: 21 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-allergyintolerance) | entry | |
section | 0..1 | BackboneElement | Assessment and Plan Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and Plan Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Family History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-familyMemberHistory) | entry | |
section | 1..1 | BackboneElement | General Status Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 0..1 | BackboneElement | History of Present Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Immunizations Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-immunization) | entry | |
section | 1..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-medicationstatement) | entry | |
section | 1..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical Findings Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Problem Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 0..1 | BackboneElement | Procedures Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Procedures Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-procedure) | entry | |
section | 0..1 | BackboneElement | Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of Systems Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Social History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social History Fixed Value: {"coding":[{"code":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-smokingstatus) | entry | |
section | 1..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-vitalsigns) | entry | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | 1..1 | Narrative | text | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource | |
id | ∑ | 0..1 | id | Logical id of this artifact |
meta | ∑ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!∑ | 0..1 | uri | A set of rules under which this content was created |
language | 1..1 | code | language Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
ccda-data-enterer-extension | I | 0..1 | Reference(Profile daf-core-pract) | dataEnterer URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-informant-extension | I | 0..* | Reference(Profile daf-core-pract) | informant URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-information-recipient-extension | I | 0..* | Reference(Profile daf-core-pract) | informationRecipient URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-participant-extension | I | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-relatedperson) | participant URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-performer-extension | I | 0..* | Reference(Profile daf-core-pract) | performer URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-authorization-extension | I | 0..* | Reference(http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent) | authorization URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | ∑ | 1..1 | Identifier | identifier |
date | ∑ | 1..1 | dateTime | date |
type | ∑ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) |
class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
title | ∑ | 1..1 | string | Document Title |
status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: HL7 BasicConfidentialityKind (required) |
subject | ∑ | 1..1 | Reference(Profile daf-core-patient) | recordTarget |
author | ∑ | 1..* | Reference(Profile daf-core-pract | http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-core-device) | author |
attester | ∑ | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
attester | ∑ | 0..* | BackboneElement | legalAuthenticator |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) Fixed Value: legal |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(Profile daf-core-pract) | party |
attester | ∑ | 0..* | BackboneElement | authenticator |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(Profile daf-core-pract) | party |
custodian | ∑ | 1..1 | Reference(Profile daf-core-organization) | custodian |
event | ∑ | 1..* | BackboneElement | serviceEvent |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
period | ∑ | 1..1 | Period | period |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
start | ∑I | 1..1 | dateTime | start |
end | ∑I | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 0..1 | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-encounter) | encompassingEncounter |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | |
section | I | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-allergyintolerance) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment and Plan Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and Plan Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6 Nested Section | |
section | I | 1..1 | BackboneElement | Family History Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-familyMemberHistory) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7 Nested Section | |
section | I | 1..1 | BackboneElement | General Status Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8 Nested Section | |
section | I | 1..1 | BackboneElement | History of Past Illness Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-condition) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9 Nested Section | |
section | I | 0..1 | BackboneElement | History of Present Illness Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-immunization) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11 Nested Section | |
section | I | 1..1 | BackboneElement | Medications Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-medicationstatement) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12 Nested Section | |
section | I | 1..1 | BackboneElement | Physical Exam Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical Findings Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13 Nested Section | |
section | I | 0..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14 Nested Section | |
section | I | 0..1 | BackboneElement | Problem Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-condition) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | Procedures Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Procedures Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-procedure) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16 Nested Section | |
section | I | 0..1 | BackboneElement | Reason for Visit Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17 Nested Section | |
section | I | 1..1 | BackboneElement | Results Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18 Nested Section | |
section | I | 1..1 | BackboneElement | Review of Systems Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of Systems Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19 Nested Section | |
section | I | 1..1 | BackboneElement | Social History Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social History Binding: Document Section Codes (example) Fixed Value: {"coding":[{"code":"29762-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-smokingstatus) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20 Nested Section | |
section | I | 1..1 | BackboneElement | Vital Signs Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-vitalsigns) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21 Nested Section | |
section | I | 0..1 | BackboneElement | Instructions Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22 Nested Section | |
Documentation for this format |
yet to be done: Xml template
yet to be done: Json template
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 41 elements (+33 nested mandatory elements)
Fixed Value: 21 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-allergyintolerance) | entry | |
section | 0..1 | BackboneElement | Assessment and Plan Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and Plan Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Family History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-familyMemberHistory) | entry | |
section | 1..1 | BackboneElement | General Status Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 0..1 | BackboneElement | History of Present Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Immunizations Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-immunization) | entry | |
section | 1..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-medicationstatement) | entry | |
section | 1..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical Findings Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Problem Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 0..1 | BackboneElement | Procedures Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Procedures Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-procedure) | entry | |
section | 0..1 | BackboneElement | Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of Systems Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Social History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social History Fixed Value: {"coding":[{"code":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-smokingstatus) | entry | |
section | 1..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-vitalsigns) | entry | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | 1..1 | Narrative | text | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource | |
id | ∑ | 0..1 | id | Logical id of this artifact |
meta | ∑ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!∑ | 0..1 | uri | A set of rules under which this content was created |
language | 1..1 | code | language Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
ccda-data-enterer-extension | I | 0..1 | Reference(Profile daf-core-pract) | dataEnterer URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-informant-extension | I | 0..* | Reference(Profile daf-core-pract) | informant URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-information-recipient-extension | I | 0..* | Reference(Profile daf-core-pract) | informationRecipient URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-participant-extension | I | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-relatedperson) | participant URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-performer-extension | I | 0..* | Reference(Profile daf-core-pract) | performer URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
ccda-authorization-extension | I | 0..* | Reference(http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent) | authorization URL: http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | ∑ | 1..1 | Identifier | identifier |
date | ∑ | 1..1 | dateTime | date |
type | ∑ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) |
class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
title | ∑ | 1..1 | string | Document Title |
status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: HL7 BasicConfidentialityKind (required) |
subject | ∑ | 1..1 | Reference(Profile daf-core-patient) | recordTarget |
author | ∑ | 1..* | Reference(Profile daf-core-pract | http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-core-device) | author |
attester | ∑ | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
attester | ∑ | 0..* | BackboneElement | legalAuthenticator |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) Fixed Value: legal |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(Profile daf-core-pract) | party |
attester | ∑ | 0..* | BackboneElement | authenticator |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(Profile daf-core-pract) | party |
custodian | ∑ | 1..1 | Reference(Profile daf-core-organization) | custodian |
event | ∑ | 1..* | BackboneElement | serviceEvent |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
period | ∑ | 1..1 | Period | period |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
start | ∑I | 1..1 | dateTime | start |
end | ∑I | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 0..1 | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-encounter) | encompassingEncounter |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | |
section | I | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-allergyintolerance) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment and Plan Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and Plan Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6 Nested Section | |
section | I | 1..1 | BackboneElement | Family History Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-familyMemberHistory) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7 Nested Section | |
section | I | 1..1 | BackboneElement | General Status Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8 Nested Section | |
section | I | 1..1 | BackboneElement | History of Past Illness Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-condition) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9 Nested Section | |
section | I | 0..1 | BackboneElement | History of Present Illness Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-immunization) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11 Nested Section | |
section | I | 1..1 | BackboneElement | Medications Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-medicationstatement) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12 Nested Section | |
section | I | 1..1 | BackboneElement | Physical Exam Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical Findings Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13 Nested Section | |
section | I | 0..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14 Nested Section | |
section | I | 0..1 | BackboneElement | Problem Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-condition) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | Procedures Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Procedures Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-procedure) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16 Nested Section | |
section | I | 0..1 | BackboneElement | Reason for Visit Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17 Nested Section | |
section | I | 1..1 | BackboneElement | Results Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18 Nested Section | |
section | I | 1..1 | BackboneElement | Review of Systems Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of Systems Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19 Nested Section | |
section | I | 1..1 | BackboneElement | Social History Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social History Binding: Document Section Codes (example) Fixed Value: {"coding":[{"code":"29762-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-smokingstatus) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20 Nested Section | |
section | I | 1..1 | BackboneElement | Vital Signs Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Profile daf-core-vitalsigns) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21 Nested Section | |
section | I | 0..1 | BackboneElement | Instructions Section cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22 Nested Section | |
Documentation for this format |
XML Template
yet to be done: Xml template
JSON Template
yet to be done: Json template
Path | Name | Conformance | ValueSet |
Composition.language | Common Languages | extensible | Common Languages |
Composition.type | HPDocumentType | required | HPDocumentType |
Composition.class | FHIR Document Class Codes | example | FHIR Document Class Codes |
Composition.status | CompositionStatus | required | CompositionStatus |
Composition.confidentiality | HL7 BasicConfidentialityKind | required | HL7 BasicConfidentialityKind |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.event.code | v3 Code System ActCode | example | v3 Code System ActCode |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Id | Path | Details | Requirements |
dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources XPath: not(parent::f:contained and f:contained) | |
dom-1 | Composition | If the resource is contained in another resource, it SHALL NOT contain any narrative XPath: not(parent::f:contained and f:text) | |
dom-4 | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated XPath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated)) | |
dom-3 | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource XPath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))])) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
ele-1 | Composition.extension | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ext-1 | Composition.extension | Must have either extensions or value[x], not both XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')]) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) | |
cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) |