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-procedure-note-composition
A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.
The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s tolerance for the procedure. It should be detailed enough to justify the procedure, describe 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 Procedure Note.
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 22 elements (+72 nested mandatory elements)
Fixed Value: 28 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) | |
event | 1..* | BackboneElement | serviceEvent | |
period | 1..1 | Period | period | |
start | 1..1 | dateTime | start | |
end | 1..1 | dateTime | end | |
encounter | 1..1 | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-encounter) | encompassingEncounter | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies and/or adverse reactions 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 | 1..1 | BackboneElement | Complications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Complications Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 1..1 | BackboneElement | Procedure Description Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure description Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Procedure Indications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure indications Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Postprocedure Diagnosis Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Postprocedure diagnosis Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
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 | 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 | Anesthesia Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Anesthesia Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-medicationstatement | Profile daf-core-procedure) | entry | |
section | 0..1 | BackboneElement | Medical (General) History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Medical (general) history Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..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 | 0..1 | BackboneElement | Medications Administered Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Medications administered Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-medicationadministration) | entry | |
section | 0..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 | Planned Procedure Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Planned procedure Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Disposition Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure disposition Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure estimated blood loss Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Findings Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure findings Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 0..1 | BackboneElement | Procedure Implants Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure implants Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Specimens Taken Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure specimens taken Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
title | 1..1 | string | Chief complaint and reason for visit | |
code | 1..1 | CodeableConcept | code 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 | Chief complaint | |
code | 1..1 | CodeableConcept | code Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Family History Section | |
title | 1..1 | string | Family history | |
code | 1..1 | CodeableConcept | code 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 | 0..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | History of past illness | |
code | 1..1 | CodeableConcept | code 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 | History of present illness | |
code | 1..1 | CodeableConcept | code 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 | 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 | 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 | Reason for visit | |
code | 1..1 | CodeableConcept | code Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..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 | 0..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 | |
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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (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 | 1..1 | dateTime | end |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 1..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 | 0..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 and/or adverse reactions 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-cdaonfhirprocedurenote.section:section_slice_pos4 Nested Section | |
section | I | 1..1 | BackboneElement | Complications 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 | Complications Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
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-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-cdaonfhirprocedurenote.section:section_slice_pos5 Nested Section | |
section | I | 1..1 | BackboneElement | Procedure 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..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 | Procedure description Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos6 Nested Section | |
section | I | 1..1 | BackboneElement | Procedure 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..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 | Procedure indications Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos7 Nested Section | |
section | I | 1..1 | BackboneElement | Postprocedure 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..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 | Postprocedure diagnosis Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos8 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-cdaonfhirprocedurenote.section:section_slice_pos9 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-cdaonfhirprocedurenote.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
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 | 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-cdaonfhirprocedurenote.section:section_slice_pos11 Nested Section | |
section | I | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) history Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos12 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos13 Nested Section | |
section | I | 0..1 | BackboneElement | Medications Administered 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 | Medications administered Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
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(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-medicationadministration) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos14 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | Planned 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..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 | Planned procedure Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
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(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-cdaonfhirprocedurenote.section:section_slice_pos16 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure disposition Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos17 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure 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 | 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-cdaonfhirprocedurenote.section:section_slice_pos18 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure findings Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
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(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-cdaonfhirprocedurenote.section:section_slice_pos19 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure implants Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
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(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-cdaonfhirprocedurenote.section:section_slice_pos20 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure specimens taken Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos21 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 | Chief complaint and reason for visit | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos22 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 | Chief complaint | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos23 Nested Section | |
section | I | 0..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 | Family history | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos24 Nested Section | |
section | I | 0..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 | History of past illness | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos25 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 | History of present illness | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos26 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-cdaonfhirprocedurenote.section:section_slice_pos27 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-cdaonfhirprocedurenote.section:section_slice_pos28 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 | Reason for visit | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos29 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos30 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos31 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: 22 elements (+72 nested mandatory elements)
Fixed Value: 28 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) | |
event | 1..* | BackboneElement | serviceEvent | |
period | 1..1 | Period | period | |
start | 1..1 | dateTime | start | |
end | 1..1 | dateTime | end | |
encounter | 1..1 | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-encounter) | encompassingEncounter | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies and/or adverse reactions 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 | 1..1 | BackboneElement | Complications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Complications Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 1..1 | BackboneElement | Procedure Description Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure description Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Procedure Indications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure indications Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Postprocedure Diagnosis Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Postprocedure diagnosis Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
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 | 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 | Anesthesia Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Anesthesia Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-medicationstatement | Profile daf-core-procedure) | entry | |
section | 0..1 | BackboneElement | Medical (General) History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Medical (general) history Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..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 | 0..1 | BackboneElement | Medications Administered Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Medications administered Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-medicationadministration) | entry | |
section | 0..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 | Planned Procedure Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Planned procedure Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Disposition Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure disposition Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure estimated blood loss Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Findings Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure findings Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(Profile daf-core-condition) | entry | |
section | 0..1 | BackboneElement | Procedure Implants Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure implants Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedure Specimens Taken Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Procedure specimens taken Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
title | 1..1 | string | Chief complaint and reason for visit | |
code | 1..1 | CodeableConcept | code 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 | Chief complaint | |
code | 1..1 | CodeableConcept | code Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Family History Section | |
title | 1..1 | string | Family history | |
code | 1..1 | CodeableConcept | code 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 | 0..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | History of past illness | |
code | 1..1 | CodeableConcept | code 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 | History of present illness | |
code | 1..1 | CodeableConcept | code 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 | 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 | 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 | Reason for visit | |
code | 1..1 | CodeableConcept | code Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..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 | 0..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 | |
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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (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 | 1..1 | dateTime | end |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 1..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 | 0..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 and/or adverse reactions 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-cdaonfhirprocedurenote.section:section_slice_pos4 Nested Section | |
section | I | 1..1 | BackboneElement | Complications 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 | Complications Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
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-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-cdaonfhirprocedurenote.section:section_slice_pos5 Nested Section | |
section | I | 1..1 | BackboneElement | Procedure 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..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 | Procedure description Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos6 Nested Section | |
section | I | 1..1 | BackboneElement | Procedure 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..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 | Procedure indications Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos7 Nested Section | |
section | I | 1..1 | BackboneElement | Postprocedure 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..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 | Postprocedure diagnosis Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos8 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-cdaonfhirprocedurenote.section:section_slice_pos9 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-cdaonfhirprocedurenote.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
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 | 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-cdaonfhirprocedurenote.section:section_slice_pos11 Nested Section | |
section | I | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) history Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos12 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos13 Nested Section | |
section | I | 0..1 | BackboneElement | Medications Administered 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 | Medications administered Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
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(http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-medicationadministration) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos14 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | Planned 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..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 | Planned procedure Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
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(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-cdaonfhirprocedurenote.section:section_slice_pos16 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure disposition Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos17 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure 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 | 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-cdaonfhirprocedurenote.section:section_slice_pos18 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure findings Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
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(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-cdaonfhirprocedurenote.section:section_slice_pos19 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure implants Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
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(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-cdaonfhirprocedurenote.section:section_slice_pos20 Nested Section | |
section | I | 0..1 | BackboneElement | Procedure 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..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 | Procedure specimens taken Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
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-cdaonfhirprocedurenote.section:section_slice_pos21 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 | Chief complaint and reason for visit | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos22 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 | Chief complaint | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos23 Nested Section | |
section | I | 0..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 | Family history | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos24 Nested Section | |
section | I | 0..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 | History of past illness | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos25 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 | History of present illness | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos26 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-cdaonfhirprocedurenote.section:section_slice_pos27 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-cdaonfhirprocedurenote.section:section_slice_pos28 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 | Reason for visit | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirprocedurenote.section:section_slice_pos29 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos30 Nested Section | |
section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos31 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 | ProcedureNoteDocumentTypeCodes | required | ProcedureNoteDocumentTypeCodes |
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 |
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)) | |
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)) |