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
The official URL for this profile is:
http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical
A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members. The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.
This profile 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 History and Physical.
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 41 elements (+33 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Allergies Profile) | entry | |
section | 0..1 | BackboneElement | Assessment and Plan Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and Plan Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Family History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference() | entry | |
section | 1..1 | BackboneElement | General Status Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Condition Profile) | entry | |
section | 0..1 | BackboneElement | History of Present Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Immunizations Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Immunization Profile) | entry | |
section | 1..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Medication Statement Profile) | entry | |
section | 1..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical Findings Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Problem Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Condition Profile) | entry | |
section | 0..1 | BackboneElement | Procedures Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Procedures Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Procedure Profile) | entry | |
section | 0..1 | BackboneElement | Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of Systems Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Social History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social History Required Pattern: {"coding":[{"code":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Smoking Status Observation Profile) | entry | |
section | 1..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Vital Signs Profile) | entry | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | 1..1 | Narrative | text | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
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 | |
extension | Extension | Extension Slice: Unordered, Open, by Composition.url | ||
CCDA-on-FHIR-Data-Enterer | 0..1 | Reference(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..* | Extension | Extensions that cannot be ignored |
identifier | ∑ | 1..1 | Identifier | identifier |
date | ∑ | 1..1 | dateTime | date |
type | ∑ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) |
class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
title | ∑ | 1..1 | string | Document Title |
status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
subject | ∑ | 1..1 | Reference(US Core Patient Profile) | recordTarget |
author | ∑ | 1..* | Reference(US Core Practitioner), Reference(Device) | author |
attester | ∑I | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
attester | ∑I | 0..1 | BackboneElement | attester |
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..1 | code | mode Binding: CompositionAttestationMode (required) Required Pattern: legal |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
attester | ∑I | 0..* | BackboneElement | attester |
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(US Core Practitioner) | party |
custodian | ∑ | 1..1 | Reference(US Core Organization Profile) | custodian |
event | ∑I | 0..* | BackboneElement | The clinical service(s) being documented |
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 | ∑ | 0..1 | Period | The period covered by the documentation |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 0..1 | Reference(Encounter) | Context of the Composition |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code | |
section | I | 1..1 | BackboneElement | Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: Document Section Codes (example) Required Pattern: {"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(US Core Allergies Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment and Plan Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6 Nested Section | |
section | I | 1..1 | BackboneElement | Family History Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Binding: Document Section Codes (example) Required Pattern: {"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() | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7 Nested Section | |
section | I | 1..1 | BackboneElement | General Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8 Nested Section | |
section | I | 1..1 | BackboneElement | History of Past Illness Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Binding: Document Section Codes (example) Required Pattern: {"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(US Core Condition Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9 Nested Section | |
section | I | 0..1 | BackboneElement | History of Present Illness Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Immunizations Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Immunization Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11 Nested Section | |
section | I | 1..1 | BackboneElement | Medications Section |
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) Required Pattern: {"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(US Core Medication Statement Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12 Nested Section | |
section | I | 1..1 | BackboneElement | Physical Exam Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13 Nested Section | |
section | I | 0..1 | BackboneElement | Plan of Treatment Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14 Nested Section | |
section | I | 0..1 | BackboneElement | Problem Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Condition Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | Procedures Section |
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) Required Pattern: {"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(US Core Procedure Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16 Nested Section | |
section | I | 0..1 | BackboneElement | Reason for Visit Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17 Nested Section | |
section | I | 1..1 | BackboneElement | Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18 Nested Section | |
section | I | 1..1 | BackboneElement | Review of Systems Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19 Nested Section | |
section | I | 1..1 | BackboneElement | Social History Section |
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) Required Pattern: {"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(US Core Smoking Status Observation Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20 Nested Section | |
section | I | 1..1 | BackboneElement | Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Vital Signs Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21 Nested Section | |
section | I | 0..1 | BackboneElement | Instructions Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22 Nested Section | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 41 elements (+33 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
type | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Allergies Profile) | entry | |
section | 0..1 | BackboneElement | Assessment and Plan Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessment and Plan Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Assessment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Assessments Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Chief Complaint Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Family History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10157-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference() | entry | |
section | 1..1 | BackboneElement | General Status Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | History of Past Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11348-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Condition Profile) | entry | |
section | 0..1 | BackboneElement | History of Present Illness Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Immunizations Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Immunization Profile) | entry | |
section | 1..1 | BackboneElement | Medications Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of medication use Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Medication Statement Profile) | entry | |
section | 1..1 | BackboneElement | Physical Exam Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Physical Findings Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Plan of Treatment Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Problem Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Condition Profile) | entry | |
section | 0..1 | BackboneElement | Procedures Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Procedures Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Procedure Profile) | entry | |
section | 0..1 | BackboneElement | Reason for Visit Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Results Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Review of Systems Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Review of Systems Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Social History Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Social History Required Pattern: {"coding":[{"code":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Smoking Status Observation Profile) | entry | |
section | 1..1 | BackboneElement | Vital Signs Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Vital Signs Profile) | entry | |
section | 0..1 | BackboneElement | Instructions Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | 1..1 | Narrative | text | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
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 | |
extension | Extension | Extension Slice: Unordered, Open, by Composition.url | ||
CCDA-on-FHIR-Data-Enterer | 0..1 | Reference(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..* | Extension | Extensions that cannot be ignored |
identifier | ∑ | 1..1 | Identifier | identifier |
date | ∑ | 1..1 | dateTime | date |
type | ∑ | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) |
class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
title | ∑ | 1..1 | string | Document Title |
status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
subject | ∑ | 1..1 | Reference(US Core Patient Profile) | recordTarget |
author | ∑ | 1..* | Reference(US Core Practitioner), Reference(Device) | author |
attester | ∑I | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
attester | ∑I | 0..1 | BackboneElement | attester |
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..1 | code | mode Binding: CompositionAttestationMode (required) Required Pattern: legal |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
attester | ∑I | 0..* | BackboneElement | attester |
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(US Core Practitioner) | party |
custodian | ∑ | 1..1 | Reference(US Core Organization Profile) | custodian |
event | ∑I | 0..* | BackboneElement | The clinical service(s) being documented |
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 | ∑ | 0..1 | Period | The period covered by the documentation |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 0..1 | Reference(Encounter) | Context of the Composition |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code | |
section | I | 1..1 | BackboneElement | Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Binding: Document Section Codes (example) Required Pattern: {"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(US Core Allergies Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment and Plan Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3 Nested Section | |
section | I | 0..1 | BackboneElement | Assessment Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint and Reason for Visit Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"46239-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5 Nested Section | |
section | I | 0..1 | BackboneElement | Chief Complaint Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Chief Complaint Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6 Nested Section | |
section | I | 1..1 | BackboneElement | Family History Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Family History Binding: Document Section Codes (example) Required Pattern: {"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() | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7 Nested Section | |
section | I | 1..1 | BackboneElement | General Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | General Status Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8 Nested Section | |
section | I | 1..1 | BackboneElement | History of Past Illness Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Past Illness Binding: Document Section Codes (example) Required Pattern: {"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(US Core Condition Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9 Nested Section | |
section | I | 0..1 | BackboneElement | History of Present Illness Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | History of Present Illness Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10164-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Immunizations Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Immunizations Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Immunization Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11 Nested Section | |
section | I | 1..1 | BackboneElement | Medications Section |
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) Required Pattern: {"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(US Core Medication Statement Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12 Nested Section | |
section | I | 1..1 | BackboneElement | Physical Exam Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13 Nested Section | |
section | I | 0..1 | BackboneElement | Plan of Treatment Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14 Nested Section | |
section | I | 0..1 | BackboneElement | Problem Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Problem List Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Condition Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | Procedures Section |
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) Required Pattern: {"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(US Core Procedure Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16 Nested Section | |
section | I | 0..1 | BackboneElement | Reason for Visit Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Reason for Visit Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17 Nested Section | |
section | I | 1..1 | BackboneElement | Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18 Nested Section | |
section | I | 1..1 | BackboneElement | Review of Systems Section |
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) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19 Nested Section | |
section | I | 1..1 | BackboneElement | Social History Section |
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) Required Pattern: {"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(US Core Smoking Status Observation Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20 Nested Section | |
section | I | 1..1 | BackboneElement | Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Vital Signs Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Vital Signs Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21 Nested Section | |
section | I | 0..1 | BackboneElement | Instructions Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | Instructions Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22 Nested Section | |
Documentation for this format |
Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron
Path | Name | Conformance | ValueSet |
Composition.language | Common Languages | extensible | Common Languages |
Composition.type | HPDocumentType | required | HPDocumentType |
Composition.class | FHIR Document Class Codes | example | FHIR Document Class Codes |
Composition.status | CompositionStatus | required | CompositionStatus |
Composition.confidentiality | ConfidentialityClassification | required | ConfidentialityClassification |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.event.code | v3 Code System ActCode | example | v3 Code System ActCode |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.mode | ListMode | required | ListMode |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
Id | Path | Details | Requirements |
dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources XPath: not(parent::f:contained and f:contained) | |
dom-1 | Composition | If the resource is contained in another resource, it SHALL NOT contain any narrative XPath: not(parent::f:contained and f:text) | |
dom-4 | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated XPath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated)) | |
dom-3 | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource XPath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))])) | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ele-1 | Composition.attester | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ele-1 | Composition.event | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) | |
ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
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)) |