Current Build

This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: CCDA-on-FHIR-Discharge-Summary

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Discharge-Summary

The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/):

The reason for hospitalization (the admission)

The procedures performed, as applicable

The care, treatment, and services provided

The patients condition and disposition at discharge

Information provided to the patient and family

Provisions for follow-up care

The best practice for a Discharge Summary is to include the discharge disposition in the display of the header.

This profile builds on C-CDA on FHIR US Realm Header.

This profile was published on Thu Dec 08 06:39:19 AEDT 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 Discharge Summary.

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (required)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and/or adverse reactions
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Allergies Profile)entry
... section 1..1BackboneElementHospital Course Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8648-8"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementDischarge Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge diagnosis
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11535-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementDischarge Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge medications
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10183-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Medication Statement Profile)entry
... section 0..1BackboneElementChief Complaint and Reason for Visit Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementChief Complaint Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementFamily History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference()entry
... section 0..1BackboneElementFunctional Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47420-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementAdmission Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital admission diagnosis
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46241-6"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHistory of Past Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Condition Profile)entry
... section 0..1BackboneElementHistory of Present Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementImmunizations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptImmunizations
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Immunization Profile)entry
... section 0..1BackboneElementAdmission Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications on admission
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"42346-7"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHospital Consultations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital consultations
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18841-7"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProblem Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Condition Profile)entry
... section 0..1BackboneElementProcedures Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of procedures
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Procedure Profile)entry
... section 0..1BackboneElementReason for Visit Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHospital Discharge Instructions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge instructions
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8653-8"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementReview of Systems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementSocial History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Smoking Status Observation Profile)entry
... section 0..1BackboneElementVital Signs Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Vital Signs Profile)entry
... section 0..1BackboneElementHospital Discharge Physical Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge physical
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10184-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHospital Discharge Studies Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge studies summary
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11493-4"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementNutrition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text 1..1Narrativetext

doco Documentation for this format

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id ∑0..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension ExtensionExtension
Slice: Unordered, Open, by Composition.url
... CCDA-on-FHIR-Data-Enterer 0..1Reference(US Core Practitioner)dataEnterer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
... CCDA-on-FHIR-Informant 0..*Reference(US Core Practitioner)informant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant
... CCDA-on-FHIR-Information-Recipient 0..*Reference(US Core Practitioner)informationRecipient
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
... CCDA-on-FHIR-Participant 0..*Reference(RelatedPerson)participant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant
... CCDA-on-FHIR-Performer 0..*Reference(US Core Practitioner)performer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer
... CCDA-on-FHIR-Authorization 0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (required)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... subject ∑1..1Reference(US Core Patient Profile)recordTarget
... author ∑1..*Reference(US Core Practitioner), Reference(Device)author
... attester ∑IBackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑I0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..1codemode
Binding: CompositionAttestationMode (required)
Required Pattern: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... attester ∑I0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... custodian ∑1..1Reference(US Core Organization Profile)custodian
... event ∑I0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
... section I1..1BackboneElementAllergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and/or adverse reactions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Allergies Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos2
Nested Section
... section I1..1BackboneElementHospital Course Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8648-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos3
Nested Section
... section I1..1BackboneElementDischarge Diagnosis Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11535-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos4
Nested Section
... section I0..1BackboneElementDischarge Medications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge medications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10183-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Medication Statement Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos5
Nested Section
... section I0..1BackboneElementChief Complaint and Reason for Visit Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos6
Nested Section
... section I0..1BackboneElementChief Complaint Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos7
Nested Section
... section I0..1BackboneElementFamily History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference()entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos8
Nested Section
... section I0..1BackboneElementFunctional Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47420-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos9
Nested Section
... section I0..1BackboneElementAdmission Diagnosis Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital admission diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46241-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos10
Nested Section
... section I0..1BackboneElementHistory of Past Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Condition Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos11
Nested Section
... section I0..1BackboneElementHistory of Present Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos12
Nested Section
... section I0..1BackboneElementImmunizations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptImmunizations
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Immunization Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos13
Nested Section
... section I0..1BackboneElementAdmission Medications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications on admission
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"42346-7"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos14
Nested Section
... section I0..1BackboneElementHospital Consultations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital consultations
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18841-7"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos15
Nested Section
... section I1..1BackboneElementPlan of Treatment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos16
Nested Section
... section I0..1BackboneElementProblem Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Condition Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos17
Nested Section
... section I0..1BackboneElementProcedures Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of procedures
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Procedure Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos18
Nested Section
... section I0..1BackboneElementReason for Visit Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos19
Nested Section
... section I0..1BackboneElementHospital Discharge Instructions Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge instructions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8653-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos20
Nested Section
... section I0..1BackboneElementReview of Systems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos21
Nested Section
... section I0..1BackboneElementSocial History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Smoking Status Observation Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos22
Nested Section
... section I0..1BackboneElementVital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Vital Signs Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos23
Nested Section
... section I0..1BackboneElementHospital Discharge Physical Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge physical
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10184-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos24
Nested Section
... section I0..1BackboneElementHospital Discharge Studies Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge studies summary
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11493-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos25
Nested Section
... section I0..1BackboneElementNutrition Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos26
Nested Section

doco Documentation for this format

Differential View

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (required)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and/or adverse reactions
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Allergies Profile)entry
... section 1..1BackboneElementHospital Course Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8648-8"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementDischarge Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge diagnosis
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11535-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementDischarge Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge medications
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10183-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Medication Statement Profile)entry
... section 0..1BackboneElementChief Complaint and Reason for Visit Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementChief Complaint Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementFamily History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference()entry
... section 0..1BackboneElementFunctional Status Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47420-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementAdmission Diagnosis Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital admission diagnosis
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46241-6"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHistory of Past Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Condition Profile)entry
... section 0..1BackboneElementHistory of Present Illness Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementImmunizations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptImmunizations
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Immunization Profile)entry
... section 0..1BackboneElementAdmission Medications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications on admission
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"42346-7"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHospital Consultations Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital consultations
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18841-7"}]}
.... text 1..1Narrativetext
... section 1..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProblem Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Condition Profile)entry
... section 0..1BackboneElementProcedures Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of procedures
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Procedure Profile)entry
... section 0..1BackboneElementReason for Visit Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHospital Discharge Instructions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge instructions
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8653-8"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementReview of Systems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementSocial History Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Smoking Status Observation Profile)entry
... section 0..1BackboneElementVital Signs Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Vital Signs Profile)entry
... section 0..1BackboneElementHospital Discharge Physical Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge physical
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10184-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementHospital Discharge Studies Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge studies summary
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11493-4"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementNutrition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text 1..1Narrativetext

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id ∑0..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension ExtensionExtension
Slice: Unordered, Open, by Composition.url
... CCDA-on-FHIR-Data-Enterer 0..1Reference(US Core Practitioner)dataEnterer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
... CCDA-on-FHIR-Informant 0..*Reference(US Core Practitioner)informant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant
... CCDA-on-FHIR-Information-Recipient 0..*Reference(US Core Practitioner)informationRecipient
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
... CCDA-on-FHIR-Participant 0..*Reference(RelatedPerson)participant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant
... CCDA-on-FHIR-Performer 0..*Reference(US Core Practitioner)performer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer
... CCDA-on-FHIR-Authorization 0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConceptDischarge Summary
Binding: DischargeSummaryDocumentTypeCode (required)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... subject ∑1..1Reference(US Core Patient Profile)recordTarget
... author ∑1..*Reference(US Core Practitioner), Reference(Device)author
... attester ∑IBackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑I0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..1codemode
Binding: CompositionAttestationMode (required)
Required Pattern: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... attester ∑I0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... custodian ∑1..1Reference(US Core Organization Profile)custodian
... event ∑I0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
... section I1..1BackboneElementAllergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies and/or adverse reactions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Allergies Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos2
Nested Section
... section I1..1BackboneElementHospital Course Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8648-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos3
Nested Section
... section I1..1BackboneElementDischarge Diagnosis Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11535-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos4
Nested Section
... section I0..1BackboneElementDischarge Medications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge medications
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10183-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Medication Statement Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos5
Nested Section
... section I0..1BackboneElementChief Complaint and Reason for Visit Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos6
Nested Section
... section I0..1BackboneElementChief Complaint Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos7
Nested Section
... section I0..1BackboneElementFamily History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference()entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos8
Nested Section
... section I0..1BackboneElementFunctional Status Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptFunctional status
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47420-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos9
Nested Section
... section I0..1BackboneElementAdmission Diagnosis Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital admission diagnosis
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46241-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos10
Nested Section
... section I0..1BackboneElementHistory of Past Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Condition Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos11
Nested Section
... section I0..1BackboneElementHistory of Present Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos12
Nested Section
... section I0..1BackboneElementImmunizations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptImmunizations
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Immunization Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos13
Nested Section
... section I0..1BackboneElementAdmission Medications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptMedications on admission
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"42346-7"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos14
Nested Section
... section I0..1BackboneElementHospital Consultations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital consultations
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18841-7"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos15
Nested Section
... section I1..1BackboneElementPlan of Treatment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of treatment
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos16
Nested Section
... section I0..1BackboneElementProblem Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Condition Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos17
Nested Section
... section I0..1BackboneElementProcedures Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of procedures
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Procedure Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos18
Nested Section
... section I0..1BackboneElementReason for Visit Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos19
Nested Section
... section I0..1BackboneElementHospital Discharge Instructions Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge instructions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8653-8"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos20
Nested Section
... section I0..1BackboneElementReview of Systems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos21
Nested Section
... section I0..1BackboneElementSocial History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSocial history
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"code":"29762-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Smoking Status Observation Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos22
Nested Section
... section I0..1BackboneElementVital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Vital Signs Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos23
Nested Section
... section I0..1BackboneElementHospital Discharge Physical Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge physical
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10184-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos24
Nested Section
... section I0..1BackboneElementHospital Discharge Studies Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHospital discharge studies summary
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11493-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos25
Nested Section
... section I0..1BackboneElementNutrition Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdischargesummary.section:section_slice_pos26
Nested Section

doco Documentation for this format

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D.4.1.2 Terminology Bindings

Terminology Bindings

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

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2CompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
XPath: not(parent::f:contained and f:contained)
dom-1CompositionIf the resource is contained in another resource, it SHALL NOT contain any narrative
XPath: not(parent::f:contained and f:text)
dom-4CompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
XPath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
dom-3CompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
XPath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
ele-1Composition.attesterAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.attesterAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.attesterAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.eventAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
.