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-Referral-Note
A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.
Examples of referral situations are: * When a patient is referred from a family physician to a cardiologist for cardiac evaluation. * When patient is sent by a cardiologist to an emergency department for angina. * When a patient is referred by a nurse practitioner to an audiologist for hearing screening. * When a patient is referred by a hospitalist to social services.
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 River Rock Associates.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
Example for: C-CDA on FHIR Referral Note.
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 17 elements (+56 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 | type Binding: ReferralDocumentType (required) | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code 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 | Medications 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":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Medication Statement Profile) | entry | |
section | 1..1 | BackboneElement | Reason for Referral 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":"42349-1"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Problem 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":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Condition Profile) | entry | |
section | 0..1 | BackboneElement | Assessment and Plan 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":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Plan of Treatment 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":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Functional Status 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":"47420-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Results 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":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Result Observation) | entry | |
section | 0..1 | BackboneElement | Nutrition 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":"61144-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Mental Status 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":"10190-7"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Assessment 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":"51848-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Advance Directives 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":"42348-3"}]} | |
text | 1..1 | Narrative | text | |
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 | 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 | General Status 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":"10210-3"}]} | |
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 | Immunizations Section | |
title | 1..1 | string | title | |
code | 0..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Immunization Profile) | entry | |
section | 0..1 | BackboneElement | Vital Signs 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":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Vital Signs Profile) | entry | |
section | 0..1 | BackboneElement | Social 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":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Smoking Status Observation Profile) | entry | |
section | 0..1 | BackboneElement | Review of Systems 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":"10187-3"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedures 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":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Procedure Profile) | entry | |
section | 0..1 | BackboneElement | Physical Exam 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":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Medical Equipment 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":"46264-8"}]} | |
text | 1..1 | Narrative | text | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | ∑ | 0..1 | id | Logical id of this artifact |
meta | ∑ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!∑ | 0..1 | uri | A set of rules under which this content was created |
language | 1..1 | code | language Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | Extension | Extension Slice: Unordered, Open, by Composition.url | ||
CCDA-on-FHIR-Data-Enterer | 0..1 | Reference(US Core Practitioner) | dataEnterer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer | |
CCDA-on-FHIR-Informant | 0..* | Reference(US Core Practitioner) | informant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant | |
CCDA-on-FHIR-Information-Recipient | 0..* | Reference(US Core Practitioner) | informationRecipient URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient | |
CCDA-on-FHIR-Participant | 0..* | Reference(RelatedPerson) | participant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant | |
CCDA-on-FHIR-Performer | 0..* | Reference(US Core Practitioner) | performer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer | |
CCDA-on-FHIR-Authorization | 0..* | Reference(C-CDA on FHIR Consent) | authorization URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | ∑ | 1..1 | Identifier | identifier |
date | ∑ | 1..1 | dateTime | date |
type | ∑ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required) |
class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
title | ∑ | 1..1 | string | Document Title |
status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
subject | ∑ | 1..1 | Reference(US Core Patient Profile) | recordTarget |
author | ∑ | 1..* | Reference(US Core Practitioner), Reference(Device) | author |
attester | ∑I | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
attester | ∑I | 0..1 | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..1 | code | mode Binding: CompositionAttestationMode (required) Required Pattern: legal |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
attester | ∑I | 0..* | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
custodian | ∑ | 1..1 | Reference(US Core Organization Profile) | custodian |
event | ∑I | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
period | ∑ | 0..1 | Period | The period covered by the documentation |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 0..1 | Reference(Encounter) | Context of the Composition |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code | |
section | I | 1..1 | BackboneElement | Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirreferralnote.section:section_slice_pos2 Nested Section | |
section | I | 1..1 | BackboneElement | Medications Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirreferralnote.section:section_slice_pos3 Nested Section | |
section | I | 1..1 | BackboneElement | Reason for Referral 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":"42349-1"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos4 Nested Section | |
section | I | 1..1 | BackboneElement | Problem Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Condition Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos5 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos6 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos7 Nested Section | |
section | I | 0..1 | BackboneElement | Functional Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47420-5"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos8 Nested Section | |
section | I | 0..1 | BackboneElement | Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Result Observation) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos9 Nested Section | |
section | I | 0..1 | BackboneElement | Nutrition 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":"61144-2"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Mental Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10190-7"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos11 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos12 Nested Section | |
section | I | 0..1 | BackboneElement | Advance Directives 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":"42348-3"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos13 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-cdaonfhirreferralnote.section:section_slice_pos14 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-cdaonfhirreferralnote.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | General Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos16 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-cdaonfhirreferralnote.section:section_slice_pos17 Nested Section | |
section | I | 0..1 | BackboneElement | Immunizations Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 0..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Immunization Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos18 Nested Section | |
section | I | 0..1 | BackboneElement | Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Vital Signs Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos19 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 | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","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-cdaonfhirreferralnote.section:section_slice_pos20 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos21 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos22 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos23 Nested Section | |
section | I | 0..1 | BackboneElement | Medical Equipment 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":"46264-8"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos24 Nested Section | |
Documentation for this format |
This structure is derived from C-CDA on FHIR US Realm Header
Summary
Mandatory: 17 elements (+56 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 | type Binding: ReferralDocumentType (required) | |
section | BackboneElement | Slice: Unordered, Open, by Composition.section.code | ||
section | 1..1 | BackboneElement | Allergies and Intolerances Section | |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code 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 | Medications 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":"10160-0"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Medication Statement Profile) | entry | |
section | 1..1 | BackboneElement | Reason for Referral 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":"42349-1"}]} | |
text | 1..1 | Narrative | text | |
section | 1..1 | BackboneElement | Problem 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":"11450-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Condition Profile) | entry | |
section | 0..1 | BackboneElement | Assessment and Plan 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":"51847-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Plan of Treatment 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":"18776-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Functional Status 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":"47420-5"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Results 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":"30954-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Result Observation) | entry | |
section | 0..1 | BackboneElement | Nutrition 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":"61144-2"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Mental Status 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":"10190-7"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Assessment 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":"51848-0"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Advance Directives 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":"42348-3"}]} | |
text | 1..1 | Narrative | text | |
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 | 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 | General Status 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":"10210-3"}]} | |
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 | Immunizations Section | |
title | 1..1 | string | title | |
code | 0..1 | CodeableConcept | code Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Immunization Profile) | entry | |
section | 0..1 | BackboneElement | Vital Signs 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":"8716-3"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Vital Signs Profile) | entry | |
section | 0..1 | BackboneElement | Social 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":"29762-2"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Smoking Status Observation Profile) | entry | |
section | 0..1 | BackboneElement | Review of Systems 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":"10187-3"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Procedures 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":"47519-4"}]} | |
text | 1..1 | Narrative | text | |
entry | 0..* | Reference(US Core Procedure Profile) | entry | |
section | 0..1 | BackboneElement | Physical Exam 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":"29545-1"}]} | |
text | 1..1 | Narrative | text | |
section | 0..1 | BackboneElement | Medical Equipment 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":"46264-8"}]} | |
text | 1..1 | Narrative | text | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | ∑ | 0..1 | id | Logical id of this artifact |
meta | ∑ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!∑ | 0..1 | uri | A set of rules under which this content was created |
language | 1..1 | code | language Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | Extension | Extension Slice: Unordered, Open, by Composition.url | ||
CCDA-on-FHIR-Data-Enterer | 0..1 | Reference(US Core Practitioner) | dataEnterer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer | |
CCDA-on-FHIR-Informant | 0..* | Reference(US Core Practitioner) | informant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant | |
CCDA-on-FHIR-Information-Recipient | 0..* | Reference(US Core Practitioner) | informationRecipient URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient | |
CCDA-on-FHIR-Participant | 0..* | Reference(RelatedPerson) | participant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant | |
CCDA-on-FHIR-Performer | 0..* | Reference(US Core Practitioner) | performer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer | |
CCDA-on-FHIR-Authorization | 0..* | Reference(C-CDA on FHIR Consent) | authorization URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | ∑ | 1..1 | Identifier | identifier |
date | ∑ | 1..1 | dateTime | date |
type | ∑ | 1..1 | CodeableConcept | type Binding: ReferralDocumentType (required) |
class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
title | ∑ | 1..1 | string | Document Title |
status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
subject | ∑ | 1..1 | Reference(US Core Patient Profile) | recordTarget |
author | ∑ | 1..* | Reference(US Core Practitioner), Reference(Device) | author |
attester | ∑I | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
attester | ∑I | 0..1 | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..1 | code | mode Binding: CompositionAttestationMode (required) Required Pattern: legal |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
attester | ∑I | 0..* | BackboneElement | attester |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) |
time | ∑ | 0..1 | dateTime | When composition attested |
party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
custodian | ∑ | 1..1 | Reference(US Core Organization Profile) | custodian |
event | ∑I | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
period | ∑ | 0..1 | Period | The period covered by the documentation |
detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
encounter | ∑ | 0..1 | Reference(Encounter) | Context of the Composition |
section | I | BackboneElement | Composition is broken into sections Slice: Unordered, Open, by Composition.section.code | |
section | I | 1..1 | BackboneElement | Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirreferralnote.section:section_slice_pos2 Nested Section | |
section | I | 1..1 | BackboneElement | Medications Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code 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-cdaonfhirreferralnote.section:section_slice_pos3 Nested Section | |
section | I | 1..1 | BackboneElement | Reason for Referral 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":"42349-1"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos4 Nested Section | |
section | I | 1..1 | BackboneElement | Problem Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11450-4"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Condition Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos5 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos6 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos7 Nested Section | |
section | I | 0..1 | BackboneElement | Functional Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"47420-5"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos8 Nested Section | |
section | I | 0..1 | BackboneElement | Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"30954-2"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Result Observation) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos9 Nested Section | |
section | I | 0..1 | BackboneElement | Nutrition 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":"61144-2"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos10 Nested Section | |
section | I | 0..1 | BackboneElement | Mental Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10190-7"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos11 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos12 Nested Section | |
section | I | 0..1 | BackboneElement | Advance Directives 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":"42348-3"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos13 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-cdaonfhirreferralnote.section:section_slice_pos14 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-cdaonfhirreferralnote.section:section_slice_pos15 Nested Section | |
section | I | 0..1 | BackboneElement | General Status Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"10210-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos16 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-cdaonfhirreferralnote.section:section_slice_pos17 Nested Section | |
section | I | 0..1 | BackboneElement | Immunizations Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 0..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"11369-6"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Immunization Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos18 Nested Section | |
section | I | 0..1 | BackboneElement | Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
title | 1..1 | string | title | |
code | 1..1 | CodeableConcept | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","code":"8716-3"}]} | |
text | I | 1..1 | Narrative | text |
mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(US Core Vital Signs Profile) | entry |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirreferralnote.section:section_slice_pos19 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 | code Binding: Document Section Codes (example) Required Pattern: {"coding":[{"system":"urn:oid:2.16.840.1.113883.6.1","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-cdaonfhirreferralnote.section:section_slice_pos20 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos21 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos22 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 | code 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-cdaonfhirreferralnote.section:section_slice_pos23 Nested Section | |
section | I | 0..1 | BackboneElement | Medical Equipment 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":"46264-8"}]} | |
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-cdaonfhirreferralnote.section:section_slice_pos24 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 | ReferralDocumentType | required | ReferralDocumentType |
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 |
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)) |