| Package | hl7.cda.us.ccda |
| Resource Type | StructureDefinition |
| Id | ChiefComplaintandReasonforVisitSection |
| FHIR Version | R5 |
| Source | http://hl7.org/cda/us/ccda/https://build.fhir.org/ig/HL7/CDA-ccda/StructureDefinition-ChiefComplaintandReasonforVisitSection.html |
| URL | http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection |
| Version | 4.0.0 |
| Status | draft |
| Date | 2025-06-26T21:09:45+00:00 |
| Name | ChiefComplaintandReasonforVisitSection |
| Title | Chief Complaint and Reason for Visit Section |
| Realm | us |
| Authority | hl7 |
| Description | This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Section |
| Kind | logical |
| StructureDefinition | |
| ConsultationNote | Consultation Note |
| DischargeSummary | Discharge Summary |
| HistoryandPhysical | History and Physical |
| ProcedureNote | Procedure Note |
| StructureDefinition | |
| Section | Section (CDA Class) |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition ChiefComplaintandReasonforVisitSection
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Section | C | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: no-cc-rfv |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
   templateId:section | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.13 | |
  @extension | 0..0 | |||
| code | 1..1 | CE | Chief complaint+Reason for visit Narrative | |
| @code | 1..1 | cs | Required Pattern: 46239-0 | |
 @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | ||
| text | 1..1 | xhtml | ||
| Documentation for this format | ||||
FHIR{
"resourceType": "StructureDefinition",
"id": "ChiefComplaintandReasonforVisitSection",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/logical-target",
"_valueBoolean": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode": "not-applicable"
}
]
}
},
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/xml-namespace",
"valueUri": "urn:hl7-org:v3"
},
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/xml-name",
"valueString": "section"
},
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/logical-container",
"valueUri": "http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument"
},
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/type-profile-style",
"valueCode": "cda"
}
],
"url": "http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection",
"identifier": [
{
"system": "urn:ietf:rfc:3986",
"value": "urn:oid:2.16.840.1.113883.10.20.22.2.13"
}
],
"version": "4.0.0",
"name": "ChiefComplaintandReasonforVisitSection",
"title": "Chief Complaint and Reason for Visit Section",
"status": "draft",
"date": "2025-06-26T21:09:45+00:00",
"publisher": "Health Level Seven",
"contact": [
{
"name": "HL7 International - Structured Documents",
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/structure"
}
]
}
],
"description": "This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.",
"jurisdiction": [
{
"coding": [
{
"system": "urn:iso:std:iso:3166",
"code": "US"
}
]
}
],
"fhirVersion": "5.0.0",
"mapping": [
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "logical",
"abstract": false,
"type": "http://hl7.org/cda/stds/core/StructureDefinition/Section",
"baseDefinition": "http://hl7.org/cda/stds/core/StructureDefinition/Section",
"derivation": "constraint",
"snapshot": {
"extension": [
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version",
"valueString": "2.0.1-sd"
}
],
"element": [
{
"id": "Section",
"path": "Section",
"short": "Base for all types and resources",
"definition": "Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.",
"min": 1,
"max": "1",
"base": {
"path": "Base",
"min": 0,
"max": "*"
},
"constraint": [
{
"key": "no-cc-rfv",
"severity": "error",
"human": "When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.",
"expression": "%resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()",
"source": "http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection"
}
],
"isModifier": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Section.nullFlavor",
"path": "Section.nullFlavor",
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"xmlAttr"
],
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}
},
{
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"min": 0,
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"base": {
"path": "InfrastructureRoot.realmCode",
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"max": "*"
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{
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{
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{
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}
],
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{
"key": "II-1",
"severity": "error",
"human": "An II instance must have either a root or an nullFlavor.",
"expression": "root.exists() or nullFlavor.exists()",
"source": "http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot"
}
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{
"id": "Section.typeId.nullFlavor",
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"xmlAttr"
],
"label": "Exceptional Value Detail",
"definition": "If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.",
"min": 0,
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},
{
"id": "Section.typeId.assigningAuthorityName",
"path": "Section.typeId.assigningAuthorityName",
"representation": [
"xmlAttr"
],
"label": "Assigning Authority Name",
"definition": "A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.",
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"max": "1",
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{
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{
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"path": "Section.typeId.displayable",
"representation": [
"xmlAttr"
],
"label": "Displayable",
"definition": "Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).",
"min": 0,
"max": "1",
"base": {
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{
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}
]
},
{
"id": "Section.typeId.root",
"path": "Section.typeId.root",
"representation": [
"xmlAttr"
],
"label": "Root",
"definition": "Identifies the type as an HL7 Registered model",
"min": 1,
"max": "1",
"base": {
"path": "II.root",
"min": 0,
"max": "1"
},
"type": [
{
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"http://hl7.org/cda/stds/core/StructureDefinition/oid",
"http://hl7.org/cda/stds/core/StructureDefinition/uuid",
"http://hl7.org/cda/stds/core/StructureDefinition/ruid"
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}
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"fixedString": "2.16.840.1.113883.1.3"
},
{
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"path": "Section.typeId.extension",
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],
"label": "Extension",
"definition": "A character string as a unique identifier within the scope of the identifier root.",
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{
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"slicing": {
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{
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],
"rules": "open"
},
"definition": "When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question",
"min": 1,
"max": "*",
"base": {
"path": "InfrastructureRoot.templateId",
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{
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},
{
"id": "Section.templateId:section",
"path": "Section.templateId",
"sliceName": "section",
"definition": "When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question",
"min": 1,
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"base": {
"path": "InfrastructureRoot.templateId",
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{
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{
"id": "Section.templateId:section.nullFlavor",
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"representation": [
"xmlAttr"
],
"label": "Exceptional Value Detail",
"definition": "If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.",
"min": 0,
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"path": "ANY.nullFlavor",
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"type": [
{
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],
"binding": {
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{
"id": "Section.templateId:section.assigningAuthorityName",
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],
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{
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{
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],
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{
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}
],
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{
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],
"label": "Extension",
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},
{
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],
"min": 0,
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"base": {
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{
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}
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},
{
"id": "Section.classCode",
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}
],
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}
},
{
"id": "Section.moodCode",
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],
"min": 0,
"max": "1",
"base": {
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"type": [
{
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}
],
"fixedCode": "EVN",
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},
{
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{
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]
},
{
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{
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],
"label": "Exceptional Value Detail",
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}
],
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}
},
{
"id": "Section.code.code",
"path": "Section.code.code",
"representation": [
"xmlAttr"
],
"label": "Code",
"definition": "The plain code symbol defined by the code system. For example, \"784.0\" is the code symbol of the ICD-9 code \"784.0\" for headache.",
"min": 1,
"max": "1",
"base": {
"path": "CD.code",
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],
"patternCode": "46239-0"
},
{
"id": "Section.code.codeSystem",
"path": "Section.code.codeSystem",
"representation": [
"xmlAttr"
],
"label": "Code System",
"definition": "Specifies the code system that defines the code.",
"min": 1,
"max": "1",
"base": {
"path": "CD.codeSystem",
"min": 0,
"max": "1"
},
"type": [
{
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},
{
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],
"label": "Code System Name",
"definition": "The common name of the coding system.",
"min": 0,
"max": "1",
"base": {
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},
"type": [
{
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}
]
},
{
"id": "Section.code.codeSystemVersion",
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"representation": [
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],
"label": "Code System Version",
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{
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}
]
},
{
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"xmlAttr"
],
"label": "Display Name",
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"min": 0,
"max": "1",
"base": {
"path": "CD.displayName",
"min": 0,
"max": "1"
},
"type": [
{
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}
]
},
{
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{
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"valueUri": "urn:hl7-org:sdtc"
},
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/xml-name",
"valueString": "valueSet"
}
],
"path": "Section.code.sdtcValueSet",
"representation": [
"xmlAttr"
],
"definition": "The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.",
"min": 0,
"max": "1",
"base": {
"path": "CD.valueSet",
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},
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{
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}
]
},
{
"id": "Section.code.sdtcValueSetVersion",
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{
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"valueUri": "urn:hl7-org:sdtc"
},
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/xml-name",
"valueString": "valueSetVersion"
}
],
"path": "Section.code.sdtcValueSetVersion",
"representation": [
"xmlAttr"
],
"definition": "The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.",
"min": 0,
"max": "1",
"base": {
"path": "CD.sdtcValueSetVersion",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string",
"profile": [
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]
}
]
},
{
"id": "Section.code.originalText",
"path": "Section.code.originalText",
"label": "Original Text",
"definition": "The text or phrase used as the basis for the coding.",
"min": 0,
"max": "1",
"base": {
"path": "CD.originalText",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/ED"
}
]
},
{
"id": "Section.code.qualifier",
"path": "Section.code.qualifier",
"label": "Qualifier",
"definition": "Specifies additional codes that increase the specificity of the the primary code.",
"min": 0,
"max": "0",
"base": {
"path": "CD.qualifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/CR"
}
]
},
{
"id": "Section.code.translation",
"path": "Section.code.translation",
"representation": [
"typeAttr"
],
"label": "Translation",
"definition": "A set of other concept descriptors that translate this concept descriptor into other code systems.",
"min": 0,
"max": "*",
"base": {
"path": "CD.translation",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/CD"
}
]
},
{
"id": "Section.title",
"path": "Section.title",
"min": 1,
"max": "1",
"base": {
"path": "Section.title",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/ST"
}
]
},
{
"id": "Section.text",
"path": "Section.text",
"representation": [
"cdaText"
],
"min": 1,
"max": "1",
"base": {
"path": "Section.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "xhtml"
}
]
},
{
"id": "Section.confidentialityCode",
"path": "Section.confidentialityCode",
"min": 0,
"max": "1",
"base": {
"path": "Section.confidentialityCode",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/CE"
}
]
},
{
"id": "Section.languageCode",
"path": "Section.languageCode",
"min": 0,
"max": "1",
"base": {
"path": "Section.languageCode",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/CS"
}
],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"id": "Section.subject",
"path": "Section.subject",
"min": 0,
"max": "1",
"base": {
"path": "Section.subject",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Subject"
}
]
},
{
"id": "Section.author",
"path": "Section.author",
"min": 0,
"max": "*",
"base": {
"path": "Section.author",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Author"
}
]
},
{
"id": "Section.informant",
"path": "Section.informant",
"min": 0,
"max": "*",
"base": {
"path": "Section.informant",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Informant"
}
]
},
{
"id": "Section.entry",
"path": "Section.entry",
"min": 0,
"max": "*",
"base": {
"path": "Section.entry",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Entry"
}
]
},
{
"id": "Section.component",
"path": "Section.component",
"min": 0,
"max": "*",
"base": {
"path": "Section.component",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot"
}
]
},
{
"id": "Section.component.nullFlavor",
"path": "Section.component.nullFlavor",
"representation": [
"xmlAttr"
],
"label": "Exceptional Value Detail",
"definition": "If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.",
"min": 0,
"max": "1",
"base": {
"path": "ANY.nullFlavor",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"
]
}
],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor"
}
},
{
"id": "Section.component.realmCode",
"path": "Section.component.realmCode",
"definition": "When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question",
"min": 0,
"max": "*",
"base": {
"path": "InfrastructureRoot.realmCode",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/CS"
}
]
},
{
"id": "Section.component.typeId",
"path": "Section.component.typeId",
"definition": "When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.",
"min": 0,
"max": "1",
"base": {
"path": "InfrastructureRoot.typeId",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/II"
}
],
"constraint": [
{
"key": "II-1",
"severity": "error",
"human": "An II instance must have either a root or an nullFlavor.",
"expression": "root.exists() or nullFlavor.exists()",
"source": "http://hl7.org/cda/stds/core/StructureDefinition/Section"
}
]
},
{
"id": "Section.component.typeId.nullFlavor",
"path": "Section.component.typeId.nullFlavor",
"representation": [
"xmlAttr"
],
"label": "Exceptional Value Detail",
"definition": "If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.",
"min": 0,
"max": "1",
"base": {
"path": "ANY.nullFlavor",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"
]
}
],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor"
}
},
{
"id": "Section.component.typeId.assigningAuthorityName",
"path": "Section.component.typeId.assigningAuthorityName",
"representation": [
"xmlAttr"
],
"label": "Assigning Authority Name",
"definition": "A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.",
"min": 0,
"max": "1",
"base": {
"path": "II.assigningAuthorityName",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/st-simple"
]
}
]
},
{
"id": "Section.component.typeId.displayable",
"path": "Section.component.typeId.displayable",
"representation": [
"xmlAttr"
],
"label": "Displayable",
"definition": "Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).",
"min": 0,
"max": "1",
"base": {
"path": "II.displayable",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/bl-simple"
]
}
]
},
{
"id": "Section.component.typeId.root",
"path": "Section.component.typeId.root",
"representation": [
"xmlAttr"
],
"label": "Root",
"definition": "Identifies the type as an HL7 Registered model",
"min": 1,
"max": "1",
"base": {
"path": "II.root",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/oid",
"http://hl7.org/cda/stds/core/StructureDefinition/uuid",
"http://hl7.org/cda/stds/core/StructureDefinition/ruid"
]
}
],
"fixedString": "2.16.840.1.113883.1.3"
},
{
"id": "Section.component.typeId.extension",
"path": "Section.component.typeId.extension",
"representation": [
"xmlAttr"
],
"label": "Extension",
"definition": "A character string as a unique identifier within the scope of the identifier root.",
"min": 1,
"max": "1",
"base": {
"path": "II.extension",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/st-simple"
]
}
]
},
{
"id": "Section.component.templateId",
"path": "Section.component.templateId",
"definition": "When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question",
"min": 0,
"max": "*",
"base": {
"path": "InfrastructureRoot.templateId",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/II"
}
]
},
{
"id": "Section.component.typeCode",
"path": "Section.component.typeCode",
"representation": [
"xmlAttr"
],
"definition": "Drawn from concept domain DocumentSectionType",
"min": 0,
"max": "1",
"base": {
"path": "Section.component.typeCode",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"
]
}
],
"fixedCode": "COMP"
},
{
"id": "Section.component.contextConductionInd",
"path": "Section.component.contextConductionInd",
"representation": [
"xmlAttr"
],
"min": 0,
"max": "1",
"base": {
"path": "Section.component.contextConductionInd",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/bl-simple"
]
}
],
"fixedBoolean": true
},
{
"id": "Section.component.section",
"path": "Section.component.section",
"min": 1,
"max": "1",
"base": {
"path": "Section.component.section",
"min": 1,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Section"
}
]
}
]
},
"differential": {
"element": [
{
"id": "Section",
"path": "Section",
"constraint": [
{
"key": "no-cc-rfv",
"severity": "error",
"human": "When using this section, the Chief Complaint Section and the Reason for Visit Section SHALL NOT be used.",
"expression": "%resource.component.structuredBody.component.where(section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection') or section.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection')).empty()",
"source": "http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection"
}
]
},
{
"id": "Section.templateId",
"path": "Section.templateId",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "root"
}
],
"rules": "open"
},
"min": 1
},
{
"id": "Section.templateId:section",
"path": "Section.templateId",
"sliceName": "section",
"min": 1,
"max": "1"
},
{
"id": "Section.templateId:section.root",
"path": "Section.templateId.root",
"min": 1,
"patternString": "2.16.840.1.113883.10.20.22.2.13"
},
{
"id": "Section.templateId:section.extension",
"path": "Section.templateId.extension",
"max": "0"
},
{
"id": "Section.code",
"path": "Section.code",
"short": "Chief complaint+Reason for visit Narrative",
"min": 1
},
{
"id": "Section.code.code",
"path": "Section.code.code",
"min": 1,
"patternCode": "46239-0"
},
{
"id": "Section.code.codeSystem",
"path": "Section.code.codeSystem",
"min": 1,
"patternString": "2.16.840.1.113883.6.1"
},
{
"id": "Section.title",
"path": "Section.title",
"min": 1
},
{
"id": "Section.text",
"path": "Section.text",
"min": 1
}
]
}
}