STU 1 Ballot

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

D.4.1 StructureDefinition: ccda-operative-note-composition

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/ccda/StructureDefinition/ccda-operative-note-composition

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

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 Operative Note.

This structure is derived from C-CDA on FHIR US Realm Header

Summary

Mandatory: 33 elements (+24 nested mandatory elements)
Fixed Value: 16 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of Composition.section.code

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConcepttype
Binding: SurgicalOperationNoteDocumentTypeCode (required)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementAnesthesia Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAnesthesia
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(Profile daf-core-medicationstatement | Profile daf-core-procedure)entry
... section 1..1BackboneElementComplications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptComplications
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(Profile daf-core-condition)entry
... section 1..1BackboneElementPreoperative Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPreoperative Diagnosis
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10219-4"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementProcedure Estimated Blood Loss Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Estimated Blood Loss
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementProcedure Findings Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Findings
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(Profile daf-core-condition)entry
... section 1..1BackboneElementProcedure Specimens Taken Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Specimens Taken
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementOperative Note Surgical Procedure Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Surgical Procedure
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10223-6"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPlanned Procedure Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlanned Procedure
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Disposition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Disposition
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementSurgical Drains Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSurgical Drains
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11537-8"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Indications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Indications
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementOperative Note Fluids Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Fluids
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10216-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Implants Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Implants
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementPostoperative Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPostoperative Diagnosis
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10218-6"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementProcedure Description Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Description
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]}
.... text 1..1Narrativetext

doco Documentation for this format

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*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..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... ccda-data-enterer-extension I0..1Reference(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 I0..*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 I0..*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 I0..*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 I0..*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 I0..*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..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConcepttype
Binding: SurgicalOperationNoteDocumentTypeCode (required)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: HL7 BasicConfidentialityKind (required)
... subject ∑1..1Reference(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 ∑BackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑0..*BackboneElementlegalAuthenticator
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
Fixed Value: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Profile daf-core-pract)party
... attester ∑0..*BackboneElementauthenticator
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Profile daf-core-pract)party
... custodian ∑1..1Reference(Profile daf-core-organization)custodian
... event ∑1..*BackboneElementserviceEvent
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑1..1Periodperiod
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... start ∑I1..1dateTimestart
..... end ∑I0..1dateTimeEnd time with inclusive boundary, if not ongoing
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-encounter)encompassingEncounter
... section IBackboneElementComposition 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 I1..1BackboneElementAnesthesia 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAnesthesia
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Profile daf-core-medicationstatement | Profile daf-core-procedure)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos2
Nested Section
... section I1..1BackboneElementComplications 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptComplications
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Profile daf-core-condition)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos3
Nested Section
... section I1..1BackboneElementPreoperative Diagnosis 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPreoperative Diagnosis
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10219-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos4
Nested Section
... section I1..1BackboneElementProcedure Estimated Blood Loss 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Estimated Blood Loss
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos5
Nested Section
... section I1..1BackboneElementProcedure Findings 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Findings
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Profile daf-core-condition)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos6
Nested Section
... section I1..1BackboneElementProcedure Specimens Taken 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Specimens Taken
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos7
Nested Section
... section I0..1BackboneElementOperative Note Surgical Procedure 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Surgical Procedure
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10223-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos8
Nested Section
... section I0..1BackboneElementPlan 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos9
Nested Section
... section I0..1BackboneElementPlanned Procedure 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlanned Procedure
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos10
Nested Section
... section I0..1BackboneElementProcedure Disposition 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Disposition
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos11
Nested Section
... section I0..1BackboneElementSurgical Drains 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSurgical Drains
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11537-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos12
Nested Section
... section I0..1BackboneElementProcedure Indications 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Indications
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos13
Nested Section
... section I0..1BackboneElementOperative Note Fluids 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Fluids
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10216-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos14
Nested Section
... section I0..1BackboneElementProcedure Implants 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Implants
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos15
Nested Section
... section I1..1BackboneElementPostoperative Diagnosis 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPostoperative Diagnosis
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10218-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos16
Nested Section
... section I1..1BackboneElementProcedure Description 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Description
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos17
Nested Section

doco 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: 33 elements (+24 nested mandatory elements)
Fixed Value: 16 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of Composition.section.code

Differential View

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConcepttype
Binding: SurgicalOperationNoteDocumentTypeCode (required)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementAnesthesia Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAnesthesia
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(Profile daf-core-medicationstatement | Profile daf-core-procedure)entry
... section 1..1BackboneElementComplications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptComplications
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(Profile daf-core-condition)entry
... section 1..1BackboneElementPreoperative Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPreoperative Diagnosis
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10219-4"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementProcedure Estimated Blood Loss Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Estimated Blood Loss
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementProcedure Findings Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Findings
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(Profile daf-core-condition)entry
... section 1..1BackboneElementProcedure Specimens Taken Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Specimens Taken
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementOperative Note Surgical Procedure Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Surgical Procedure
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10223-6"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPlanned Procedure Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlanned Procedure
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Disposition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Disposition
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementSurgical Drains Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSurgical Drains
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11537-8"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Indications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Indications
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementOperative Note Fluids Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Fluids
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10216-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProcedure Implants Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Implants
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementPostoperative Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPostoperative Diagnosis
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10218-6"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementProcedure Description Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Description
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]}
.... text 1..1Narrativetext

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*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..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... ccda-data-enterer-extension I0..1Reference(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 I0..*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 I0..*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 I0..*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 I0..*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 I0..*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..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConcepttype
Binding: SurgicalOperationNoteDocumentTypeCode (required)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: HL7 BasicConfidentialityKind (required)
... subject ∑1..1Reference(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 ∑BackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑0..*BackboneElementlegalAuthenticator
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
Fixed Value: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Profile daf-core-pract)party
... attester ∑0..*BackboneElementauthenticator
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Profile daf-core-pract)party
... custodian ∑1..1Reference(Profile daf-core-organization)custodian
... event ∑1..*BackboneElementserviceEvent
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑1..1Periodperiod
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... start ∑I1..1dateTimestart
..... end ∑I0..1dateTimeEnd time with inclusive boundary, if not ongoing
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-encounter)encompassingEncounter
... section IBackboneElementComposition 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 I1..1BackboneElementAnesthesia 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAnesthesia
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Profile daf-core-medicationstatement | Profile daf-core-procedure)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos2
Nested Section
... section I1..1BackboneElementComplications 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptComplications
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Profile daf-core-condition)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos3
Nested Section
... section I1..1BackboneElementPreoperative Diagnosis 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPreoperative Diagnosis
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10219-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos4
Nested Section
... section I1..1BackboneElementProcedure Estimated Blood Loss 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Estimated Blood Loss
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos5
Nested Section
... section I1..1BackboneElementProcedure Findings 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Findings
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Profile daf-core-condition)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos6
Nested Section
... section I1..1BackboneElementProcedure Specimens Taken 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Specimens Taken
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos7
Nested Section
... section I0..1BackboneElementOperative Note Surgical Procedure 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Surgical Procedure
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10223-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos8
Nested Section
... section I0..1BackboneElementPlan 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos9
Nested Section
... section I0..1BackboneElementPlanned Procedure 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlanned Procedure
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos10
Nested Section
... section I0..1BackboneElementProcedure Disposition 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Disposition
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos11
Nested Section
... section I0..1BackboneElementSurgical Drains 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSurgical Drains
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11537-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos12
Nested Section
... section I0..1BackboneElementProcedure Indications 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Indications
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos13
Nested Section
... section I0..1BackboneElementOperative Note Fluids 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptOperative Note Fluids
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10216-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos14
Nested Section
... section I0..1BackboneElementProcedure Implants 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Implants
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos15
Nested Section
... section I1..1BackboneElementPostoperative Diagnosis 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPostoperative Diagnosis
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10218-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos16
Nested Section
... section I1..1BackboneElementProcedure Description 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProcedure Description
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhiroperativenote.section:section_slice_pos17
Nested Section

doco Documentation for this format

XML Template

yet to be done: Xml template

JSON Template

yet to be done: Json template

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Composition.languageCommon LanguagesextensibleCommon Languages
Composition.typeSurgicalOperationNoteDocumentTypeCoderequiredSurgicalOperationNoteDocumentTypeCode
Composition.classFHIR Document Class CodesexampleFHIR Document Class Codes
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityHL7 BasicConfidentialityKindrequiredHL7 BasicConfidentialityKind
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.event.codev3 Code System ActCodeexamplev3 Code System ActCode
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2CompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
XPath: not(parent::f:contained and f:contained)
dom-1CompositionIf the resource is contained in another resource, it SHALL NOT contain any narrative
XPath: not(parent::f:contained and f:text)
dom-4CompositionIf 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-3CompositionIf 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-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
ele-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
ele-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
ele-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
ele-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
ele-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
ele-1Composition.extensionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ext-1Composition.extensionMust have either extensions or value[x], not both
XPath: exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
.