Current Build

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

D.4.1 StructureDefinition: CCDA-on-FHIR-Progress-Note

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note

This profile represents a patients clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

Tabers medical dictionary defines a Progress Note as An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.

Mosbys medical dictionary defines a Progress Note as Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned.

A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.

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 Progress Note.

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

Summary

Mandatory: 1 element (+48 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConcepttype
Binding: ProgressNoteDocumentTypeCode (required)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 0..1BackboneElementAssessment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProblems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Condition Profile)entry
... section 0..1BackboneElementResults Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests and/or laboratory data
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Result Observation)entry
... section 0..1BackboneElementNutrition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementVital Signs Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Vital Signs Profile)entry
... section 0..1BackboneElementSubjective Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSubjective
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61150-9"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementReview of Systems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPhysical Exam Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementObjective Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptObjective
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61149-1"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementMedications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Medication Statement Profile)entry
... section 0..1BackboneElementInstructions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptInstructions
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementInterventions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptInterventions provided
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"62387-6"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementChief Complaint Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies, adverse reactions, alerts
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Allergies Profile)entry
... section 0..1BackboneElementAssessment and Plan Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]}
.... text 1..1Narrativetext

doco Documentation for this format

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id ∑0..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension ExtensionExtension
Slice: Unordered, Open, by Composition.url
... CCDA-on-FHIR-Data-Enterer 0..1Reference(US Core Practitioner)dataEnterer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
... CCDA-on-FHIR-Informant 0..*Reference(US Core Practitioner)informant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant
... CCDA-on-FHIR-Information-Recipient 0..*Reference(US Core Practitioner)informationRecipient
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
... CCDA-on-FHIR-Participant 0..*Reference(RelatedPerson)participant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant
... CCDA-on-FHIR-Performer 0..*Reference(US Core Practitioner)performer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer
... CCDA-on-FHIR-Authorization 0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConcepttype
Binding: ProgressNoteDocumentTypeCode (required)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... subject ∑1..1Reference(US Core Patient Profile)recordTarget
... author ∑1..*Reference(US Core Practitioner), Reference(Device)author
... attester ∑IBackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑I0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..1codemode
Binding: CompositionAttestationMode (required)
Required Pattern: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... attester ∑I0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... custodian ∑1..1Reference(US Core Organization Profile)custodian
... event ∑I0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
... section I0..1BackboneElementAssessment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos2
Nested Section
... section I0..1BackboneElementPlan of Treatment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos3
Nested Section
... section I0..1BackboneElementProblems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Condition Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos4
Nested Section
... section I0..1BackboneElementResults Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests and/or laboratory data
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Result Observation)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos5
Nested Section
... section I0..1BackboneElementNutrition Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos6
Nested Section
... section I0..1BackboneElementVital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Vital Signs Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos7
Nested Section
... section I0..1BackboneElementSubjective Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSubjective
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61150-9"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos8
Nested Section
... section I0..1BackboneElementReview of Systems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos9
Nested Section
... section I0..1BackboneElementPhysical Exam Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos10
Nested Section
... section I0..1BackboneElementObjective Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptObjective
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61149-1"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos11
Nested Section
... section I0..1BackboneElementMedications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Medication Statement Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos12
Nested Section
... section I0..1BackboneElementInstructions Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptInstructions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos13
Nested Section
... section I0..1BackboneElementInterventions Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptInterventions provided
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"62387-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos14
Nested Section
... section I0..1BackboneElementChief Complaint Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos15
Nested Section
... section I0..1BackboneElementAllergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies, adverse reactions, alerts
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Allergies Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos16
Nested Section
... section I0..1BackboneElementAssessment and Plan Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos17
Nested Section

doco Documentation for this format

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

Summary

Mandatory: 1 element (+48 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConcepttype
Binding: ProgressNoteDocumentTypeCode (required)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 0..1BackboneElementAssessment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPlan of Treatment Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementProblems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Condition Profile)entry
... section 0..1BackboneElementResults Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests and/or laboratory data
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Result Observation)entry
... section 0..1BackboneElementNutrition Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementVital Signs Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Vital Signs Profile)entry
... section 0..1BackboneElementSubjective Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptSubjective
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61150-9"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementReview of Systems Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementPhysical Exam Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementObjective Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptObjective
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61149-1"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementMedications Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Medication Statement Profile)entry
... section 0..1BackboneElementInstructions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptInstructions
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementInterventions Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptInterventions provided
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"62387-6"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementChief Complaint Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text 1..1Narrativetext
... section 0..1BackboneElementAllergies and Intolerances Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies, adverse reactions, alerts
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text 1..1Narrativetext
.... entry 0..*Reference(US Core Allergies Profile)entry
... section 0..1BackboneElementAssessment and Plan Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]}
.... text 1..1Narrativetext

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id ∑0..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension ExtensionExtension
Slice: Unordered, Open, by Composition.url
... CCDA-on-FHIR-Data-Enterer 0..1Reference(US Core Practitioner)dataEnterer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
... CCDA-on-FHIR-Informant 0..*Reference(US Core Practitioner)informant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant
... CCDA-on-FHIR-Information-Recipient 0..*Reference(US Core Practitioner)informationRecipient
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
... CCDA-on-FHIR-Participant 0..*Reference(RelatedPerson)participant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant
... CCDA-on-FHIR-Performer 0..*Reference(US Core Practitioner)performer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer
... CCDA-on-FHIR-Authorization 0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConcepttype
Binding: ProgressNoteDocumentTypeCode (required)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... subject ∑1..1Reference(US Core Patient Profile)recordTarget
... author ∑1..*Reference(US Core Practitioner), Reference(Device)author
... attester ∑IBackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑I0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..1codemode
Binding: CompositionAttestationMode (required)
Required Pattern: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... attester ∑I0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... custodian ∑1..1Reference(US Core Organization Profile)custodian
... event ∑I0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
... section I0..1BackboneElementAssessment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessments
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51848-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos2
Nested Section
... section I0..1BackboneElementPlan of Treatment Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPlan of Treatment
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"18776-5"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos3
Nested Section
... section I0..1BackboneElementProblems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptProblem list
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Condition Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos4
Nested Section
... section I0..1BackboneElementResults Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptRelevant diagnostic tests and/or laboratory data
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Result Observation)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos5
Nested Section
... section I0..1BackboneElementNutrition Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDiet and nutrition
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61144-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos6
Nested Section
... section I0..1BackboneElementVital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptVital signs
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Vital Signs Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos7
Nested Section
... section I0..1BackboneElementSubjective Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptSubjective
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61150-9"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos8
Nested Section
... section I0..1BackboneElementReview of Systems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptReview of systems
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10187-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos9
Nested Section
... section I0..1BackboneElementPhysical Exam Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptPhysical findings
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"29545-1"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos10
Nested Section
... section I0..1BackboneElementObjective Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptObjective
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"61149-1"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos11
Nested Section
... section I0..1BackboneElementMedications Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptHistory of medication use
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10160-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Medication Statement Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos12
Nested Section
... section I0..1BackboneElementInstructions Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptInstructions
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"69730-0"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos13
Nested Section
... section I0..1BackboneElementInterventions Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptInterventions provided
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"62387-6"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos14
Nested Section
... section I0..1BackboneElementChief Complaint Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptChief complaint
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10154-3"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos15
Nested Section
... section I0..1BackboneElementAllergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAllergies, adverse reactions, alerts
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"48765-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(US Core Allergies Profile)entry
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos16
Nested Section
... section I0..1BackboneElementAssessment and Plan Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptAssessment and plan
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"51847-2"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirprogressnote.section:section_slice_pos17
Nested Section

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron

 

D.4.1.2 Terminology Bindings

Terminology Bindings

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

D.4.1.3 Constraints

Constraints

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