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 
The official URL for this profile is:
http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Procedure-Note
A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.
The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
This profile 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 Procedure Note.
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 22 elements (+72 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) | |
| event | 1..* | BackboneElement | serviceEvent | |
  period | 1..1 | Period | period | |
 start | 1..1 | dateTime | start | |
| end | 1..1 | dateTime | end | |
| encounter | 1..1 | Reference(Encounter) | encompassingEncounter | |
 section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
| section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Allergies and/or adverse reactions 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 | 1..1 | BackboneElement | Complications Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Complications Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Condition Profile) | entry | |
| section | 1..1 | BackboneElement | Procedure Description Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure description Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
| text | 1..1 | Narrative | text | |
| section | 1..1 | BackboneElement | Procedure Indications Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure indications Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
| text | 1..1 | Narrative | text | |
| section | 1..1 | BackboneElement | Postprocedure Diagnosis Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Postprocedure diagnosis Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Assessment Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Assessments 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 | 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 | Anesthesia Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Anesthesia Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Medication Statement Profile) | entry | |
| section | 0..1 | BackboneElement | Medical (General) History Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Medical (general) history Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Medications Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | History of medication use 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 | 0..1 | BackboneElement | Medications Administered Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Medications administered Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference() | entry | |
| section | 0..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 | Planned Procedure Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Planned procedure Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Disposition Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure disposition Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure estimated blood loss Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Findings Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure findings Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Condition Profile) | entry | |
| section | 0..1 | BackboneElement | Procedure Implants Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure implants Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Specimens Taken Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure specimens taken Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | code 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 | code Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Family History Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | code 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 | 0..1 | BackboneElement | History of Past Illness Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | code 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 | code 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 | 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 | 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 | code Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Review of Systems Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Review of systems Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Social History Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Social history Required Pattern: {"coding":[{"code":"29762-2"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Smoking Status Observation Profile) | entry | |
| Documentation for this format | ||||
This structure is derived from C-CDA on FHIR US Realm Header
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) |
| class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
| title | ∑ | 1..1 | string | Document Title |
| status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
| confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: 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 | 1..* | BackboneElement | serviceEvent |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ∑ | 1..1 | Period | period |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| start | ∑I | 1..1 | dateTime | start |
| end | ∑I | 1..1 | dateTime | end |
| detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
| encounter | ∑ | 1..1 | Reference(Encounter) | encompassingEncounter |
| section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code | |
| section | I | 0..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 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 | 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-cdaonfhirprocedurenote.section:section_slice_pos4 Nested Section | |
| section | I | 1..1 | BackboneElement | Complications 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 | Complications Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(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-cdaonfhirprocedurenote.section:section_slice_pos5 Nested Section | |
| section | I | 1..1 | BackboneElement | Procedure Description 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 | Procedure description Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos6 Nested Section | |
| section | I | 1..1 | BackboneElement | Procedure Indications Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure indications Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos7 Nested Section | |
| section | I | 1..1 | BackboneElement | Postprocedure Diagnosis Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Postprocedure diagnosis Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos8 Nested Section | |
| section | I | 0..1 | BackboneElement | Assessment Section |
| 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-cdaonfhirprocedurenote.section:section_slice_pos9 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-cdaonfhirprocedurenote.section:section_slice_pos10 Nested Section | |
| section | I | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(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-cdaonfhirprocedurenote.section:section_slice_pos11 Nested Section | |
| section | I | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) history Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos12 Nested Section | |
| section | I | 0..1 | BackboneElement | Medications Section |
| 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-cdaonfhirprocedurenote.section:section_slice_pos13 Nested Section | |
| section | I | 0..1 | BackboneElement | Medications Administered 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 | Medications administered Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference() | entry |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos14 Nested Section | |
| section | I | 0..1 | BackboneElement | Physical Exam Section |
| 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-cdaonfhirprocedurenote.section:section_slice_pos15 Nested Section | |
| section | I | 0..1 | BackboneElement | Planned Procedure 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 | Planned procedure Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos16 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Disposition Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure disposition Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos17 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure estimated blood loss Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos18 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Findings Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure findings Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(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-cdaonfhirprocedurenote.section:section_slice_pos19 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Implants 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 | Procedure implants Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos20 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Specimens Taken Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure specimens taken Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos21 Nested Section | |
| section | I | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section |
| 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos22 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos23 Nested Section | |
| section | I | 0..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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos24 Nested Section | |
| section | I | 0..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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos25 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos26 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-cdaonfhirprocedurenote.section:section_slice_pos27 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-cdaonfhirprocedurenote.section:section_slice_pos28 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos29 Nested Section | |
| section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos30 Nested Section | |
| section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos31 Nested Section | |
| Documentation for this format | ||||
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 22 elements (+72 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) | |
| event | 1..* | BackboneElement | serviceEvent | |
| period | 1..1 | Period | period | |
| start | 1..1 | dateTime | start | |
| end | 1..1 | dateTime | end | |
| encounter | 1..1 | Reference(Encounter) | encompassingEncounter | |
| section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
| section | 0..1 | BackboneElement | Allergies and Intolerances Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Allergies and/or adverse reactions 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 | 1..1 | BackboneElement | Complications Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Complications Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Condition Profile) | entry | |
| section | 1..1 | BackboneElement | Procedure Description Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure description Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
| text | 1..1 | Narrative | text | |
| section | 1..1 | BackboneElement | Procedure Indications Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure indications Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
| text | 1..1 | Narrative | text | |
| section | 1..1 | BackboneElement | Postprocedure Diagnosis Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Postprocedure diagnosis Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Assessment Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Assessments 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 | 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 | Anesthesia Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Anesthesia Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Medication Statement Profile) | entry | |
| section | 0..1 | BackboneElement | Medical (General) History Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Medical (general) history Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Medications Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | History of medication use 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 | 0..1 | BackboneElement | Medications Administered Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Medications administered Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference() | entry | |
| section | 0..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 | Planned Procedure Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Planned procedure Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Disposition Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure disposition Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure estimated blood loss Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Findings Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure findings Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Condition Profile) | entry | |
| section | 0..1 | BackboneElement | Procedure Implants Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure implants Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Procedure Specimens Taken Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure specimens taken Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | code 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 | code Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Family History Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | code 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 | 0..1 | BackboneElement | History of Past Illness Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | code 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 | code 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 | 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 | 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 | code Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29299-5"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Review of Systems Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Review of systems Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]} | |
| text | 1..1 | Narrative | text | |
| section | 0..1 | BackboneElement | Social History Section | |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Social history Required Pattern: {"coding":[{"code":"29762-2"}]} | |
| text | 1..1 | Narrative | text | |
| entry | 0..* | Reference(US Core Smoking Status Observation Profile) | entry | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| 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 | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) |
| class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
| title | ∑ | 1..1 | string | Document Title |
| status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
| confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: 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 | 1..* | BackboneElement | serviceEvent |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ∑ | 1..1 | Period | period |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| start | ∑I | 1..1 | dateTime | start |
| end | ∑I | 1..1 | dateTime | end |
| detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
| encounter | ∑ | 1..1 | Reference(Encounter) | encompassingEncounter |
| section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code | |
| section | I | 0..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 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 | 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-cdaonfhirprocedurenote.section:section_slice_pos4 Nested Section | |
| section | I | 1..1 | BackboneElement | Complications 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 | Complications Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"55109-3"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(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-cdaonfhirprocedurenote.section:section_slice_pos5 Nested Section | |
| section | I | 1..1 | BackboneElement | Procedure Description 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 | Procedure description Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29554-3"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos6 Nested Section | |
| section | I | 1..1 | BackboneElement | Procedure Indications Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure indications Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59768-2"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos7 Nested Section | |
| section | I | 1..1 | BackboneElement | Postprocedure Diagnosis Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Postprocedure diagnosis Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59769-0"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos8 Nested Section | |
| section | I | 0..1 | BackboneElement | Assessment Section |
| 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-cdaonfhirprocedurenote.section:section_slice_pos9 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-cdaonfhirprocedurenote.section:section_slice_pos10 Nested Section | |
| section | I | 0..1 | BackboneElement | Anesthesia 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 | Anesthesia Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59774-0"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(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-cdaonfhirprocedurenote.section:section_slice_pos11 Nested Section | |
| section | I | 0..1 | BackboneElement | Medical (General) 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 | Medical (general) history Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11329-0"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos12 Nested Section | |
| section | I | 0..1 | BackboneElement | Medications Section |
| 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-cdaonfhirprocedurenote.section:section_slice_pos13 Nested Section | |
| section | I | 0..1 | BackboneElement | Medications Administered 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 | Medications administered Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29549-3"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference() | entry |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos14 Nested Section | |
| section | I | 0..1 | BackboneElement | Physical Exam Section |
| 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-cdaonfhirprocedurenote.section:section_slice_pos15 Nested Section | |
| section | I | 0..1 | BackboneElement | Planned Procedure 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 | Planned procedure Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59772-4"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos16 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Disposition Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure disposition Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59775-7"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos17 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Estimated Blood Loss Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure estimated blood loss Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59770-8"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos18 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Findings Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure findings Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59776-5"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(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-cdaonfhirprocedurenote.section:section_slice_pos19 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Implants 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 | Procedure implants Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59771-6"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos20 Nested Section | |
| section | I | 0..1 | BackboneElement | Procedure Specimens Taken Section |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 1..1 | string | title | |
| code | 1..1 | CodeableConcept | Procedure specimens taken Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"59773-2"}]} | |
| text | I | 1..1 | Narrative | text |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirprocedurenote.section:section_slice_pos21 Nested Section | |
| section | I | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section |
| 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos22 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos23 Nested Section | |
| section | I | 0..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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos24 Nested Section | |
| section | I | 0..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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos25 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos26 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-cdaonfhirprocedurenote.section:section_slice_pos27 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-cdaonfhirprocedurenote.section:section_slice_pos28 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 | code 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-cdaonfhirprocedurenote.section:section_slice_pos29 Nested Section | |
| section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos30 Nested Section | |
| section | I | 0..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-cdaonfhirprocedurenote.section:section_slice_pos31 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 | ProcedureNoteDocumentTypeCodes | required | ProcedureNoteDocumentTypeCodes |
| 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 |
| 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)) | |
| 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)) |
© HL7.org 2011+. FHIR STU3 Candidate (v1.8.0-10514) generated on Thu, Dec 8, 2016 06:39+1100. QA Page
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