| Package | hl7.cda.us.ccda |
| Type | StructureDefinition |
| Id | PreoperativeDiagnosisSection |
| FHIR Version | R5 |
| Source | http://hl7.org/cda/us/ccda/https://build.fhir.org/ig/HL7/CDA-ccda/StructureDefinition-PreoperativeDiagnosisSection.html |
| URL | http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection |
| Version | 4.0.0 |
| Status | draft |
| Date | 2025-06-26T21:09:45+00:00 |
| Name | PreoperativeDiagnosisSection |
| Title | Preoperative Diagnosis Section |
| Realm | us |
| Authority | hl7 |
| Description | The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon's opinion, the diagnosis that will be confirmed during surgery. #### Templates Used Although open templates may contain any valid CDA content, the following templates are specifically called out by this template: **Recommended Entries**: [PreoperativeDiagnosis](StructureDefinition-PreoperativeDiagnosis.html) |
| Type | http://hl7.org/cda/stds/core/StructureDefinition/Section |
| Kind | logical |
| StructureDefinition | |
| OperativeNote | Operative Note |
| StructureDefinition | |
| Act | Act (CDA Class) |
| Section | Section (CDA Class) |
| PreoperativeDiagnosis | Preoperative Diagnosis |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition PreoperativeDiagnosisSection
| 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: should-preop-dx |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:section | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.34 | |
  @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | Surgical operation note preoperative diagnosis Narrative | |
| @code | 1..1 | cs | Required Pattern: 10219-4 | |
 @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | ||
| text | 1..1 | xhtml | ||
| Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:act | |
| entry:preopDiagnosis | 0..1 | Entry | ||
 act | 1..1 | PreoperativeDiagnosis | ||
| Documentation for this format | ||||
FHIR{
"resourceType": "StructureDefinition",
"id": "PreoperativeDiagnosisSection",
"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"
},
{
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"valueString": "section"
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{
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},
{
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"valueCode": "cda"
}
],
"url": "http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection",
"identifier": [
{
"system": "urn:ietf:rfc:3986",
"value": "urn:hl7ii:2.16.840.1.113883.10.20.22.2.34:2015-08-01"
}
],
"version": "4.0.0",
"name": "PreoperativeDiagnosisSection",
"title": "Preoperative Diagnosis 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": "The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon's opinion, the diagnosis that will be confirmed during surgery.\n\n#### Templates Used\nAlthough open templates may contain any valid CDA content, the following templates are specifically called out by this template:\n\n**Recommended Entries**: [PreoperativeDiagnosis](StructureDefinition-PreoperativeDiagnosis.html)",
"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,
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"baseDefinition": "http://hl7.org/cda/stds/core/StructureDefinition/Section",
"derivation": "constraint",
"snapshot": {
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{
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"valueString": "2.0.1-sd"
}
],
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{
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"min": 1,
"max": "1",
"base": {
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"max": "*"
},
"constraint": [
{
"key": "should-preop-dx",
"severity": "warning",
"human": "SHOULD contain Preoperative Diagnosis",
"expression": "entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))",
"source": "http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection"
}
],
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{
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{
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]
},
{
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}
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{
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"source": "http://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot"
}
]
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{
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},
{
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],
"label": "Assigning Authority Name",
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]
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{
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"representation": [
"xmlAttr"
],
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{
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}
]
},
{
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"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",
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"type": [
{
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],
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},
{
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"xmlAttr"
],
"label": "Extension",
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}
]
},
{
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{
"type": "value",
"path": "root"
},
{
"type": "value",
"path": "extension"
}
],
"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,
"max": "1",
"base": {
"path": "InfrastructureRoot.templateId",
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"max": "*"
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"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/II"
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]
},
{
"id": "Section.templateId:section.nullFlavor",
"path": "Section.templateId.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",
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"path": "ANY.nullFlavor",
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}
],
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}
},
{
"id": "Section.templateId:section.assigningAuthorityName",
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"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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},
{
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"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).",
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"max": "1",
"base": {
"path": "II.displayable",
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{
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}
]
},
{
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"path": "Section.templateId.root",
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"xmlAttr"
],
"label": "Root",
"definition": "A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.",
"min": 1,
"max": "1",
"base": {
"path": "II.root",
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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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{
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}
]
},
{
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],
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}
],
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"valueSet": "http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer"
}
},
{
"id": "Section.moodCode",
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"xmlAttr"
],
"min": 0,
"max": "1",
"base": {
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{
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}
],
"fixedCode": "EVN",
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}
},
{
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{
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{
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"min": 0,
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},
{
"id": "Section.code.code",
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],
"label": "Code",
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"min": 1,
"max": "1",
"base": {
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}
],
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},
{
"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": [
{
"code": "string",
"profile": [
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"http://hl7.org/cda/stds/core/StructureDefinition/uuid",
"http://hl7.org/cda/stds/core/StructureDefinition/ruid"
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}
],
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},
{
"id": "Section.code.codeSystemName",
"path": "Section.code.codeSystemName",
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],
"label": "Code System Name",
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"min": 0,
"max": "1",
"base": {
"path": "CD.codeSystemName",
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"max": "1"
},
"type": [
{
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}
]
},
{
"id": "Section.code.codeSystemVersion",
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],
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"min": 0,
"max": "1",
"base": {
"path": "CD.codeSystemVersion",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string",
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}
]
},
{
"id": "Section.code.displayName",
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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": [
{
"code": "string",
"profile": [
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]
}
]
},
{
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{
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},
{
"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",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string",
"profile": [
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]
}
]
},
{
"id": "Section.code.sdtcValueSetVersion",
"extension": [
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/xml-namespace",
"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": [
"http://hl7.org/cda/stds/core/StructureDefinition/st-simple"
]
}
]
},
{
"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",
"slicing": {
"discriminator": [
{
"type": "profile",
"path": "act"
}
],
"rules": "open"
},
"min": 0,
"max": "*",
"base": {
"path": "Section.entry",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Entry"
}
]
},
{
"id": "Section.entry:preopDiagnosis",
"path": "Section.entry",
"sliceName": "preopDiagnosis",
"comment": "SHOULD contain zero or one [0..1] entry (CONF:1198-10096) such that it",
"min": 0,
"max": "1",
"base": {
"path": "Section.entry",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Entry"
}
]
},
{
"id": "Section.entry:preopDiagnosis.nullFlavor",
"path": "Section.entry.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.entry:preopDiagnosis.realmCode",
"path": "Section.entry.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.entry:preopDiagnosis.typeId",
"path": "Section.entry.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/InfrastructureRoot"
}
]
},
{
"id": "Section.entry:preopDiagnosis.typeId.nullFlavor",
"path": "Section.entry.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.entry:preopDiagnosis.typeId.assigningAuthorityName",
"path": "Section.entry.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.entry:preopDiagnosis.typeId.displayable",
"path": "Section.entry.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.entry:preopDiagnosis.typeId.root",
"path": "Section.entry.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.entry:preopDiagnosis.typeId.extension",
"path": "Section.entry.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.entry:preopDiagnosis.templateId",
"path": "Section.entry.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.entry:preopDiagnosis.typeCode",
"path": "Section.entry.typeCode",
"representation": [
"xmlAttr"
],
"min": 0,
"max": "1",
"base": {
"path": "Entry.typeCode",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/cs-simple"
]
}
],
"defaultValueCode": "COMP",
"binding": {
"strength": "required",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry"
}
},
{
"id": "Section.entry:preopDiagnosis.contextConductionInd",
"path": "Section.entry.contextConductionInd",
"representation": [
"xmlAttr"
],
"min": 0,
"max": "1",
"base": {
"path": "Entry.contextConductionInd",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean",
"profile": [
"http://hl7.org/cda/stds/core/StructureDefinition/bl-simple"
]
}
],
"fixedBoolean": true
},
{
"id": "Section.entry:preopDiagnosis.act",
"path": "Section.entry.act",
"comment": "SHALL contain exactly one [1..1] Preoperative Diagnosis (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.65:2015-08-01) (CONF:1198-15504).",
"min": 1,
"max": "1",
"base": {
"path": "Entry.act",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Act",
"profile": [
"http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis"
]
}
]
},
{
"id": "Section.entry:preopDiagnosis.encounter",
"path": "Section.entry.encounter",
"min": 0,
"max": "1",
"base": {
"path": "Entry.encounter",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Encounter"
}
]
},
{
"id": "Section.entry:preopDiagnosis.observation",
"path": "Section.entry.observation",
"min": 0,
"max": "1",
"base": {
"path": "Entry.observation",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Observation"
}
]
},
{
"id": "Section.entry:preopDiagnosis.observationMedia",
"path": "Section.entry.observationMedia",
"min": 0,
"max": "1",
"base": {
"path": "Entry.observationMedia",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/ObservationMedia"
}
]
},
{
"id": "Section.entry:preopDiagnosis.organizer",
"path": "Section.entry.organizer",
"min": 0,
"max": "1",
"base": {
"path": "Entry.organizer",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Organizer"
}
]
},
{
"id": "Section.entry:preopDiagnosis.procedure",
"path": "Section.entry.procedure",
"min": 0,
"max": "1",
"base": {
"path": "Entry.procedure",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Procedure"
}
]
},
{
"id": "Section.entry:preopDiagnosis.regionOfInterest",
"path": "Section.entry.regionOfInterest",
"min": 0,
"max": "1",
"base": {
"path": "Entry.regionOfInterest",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/RegionOfInterest"
}
]
},
{
"id": "Section.entry:preopDiagnosis.substanceAdministration",
"path": "Section.entry.substanceAdministration",
"min": 0,
"max": "1",
"base": {
"path": "Entry.substanceAdministration",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration"
}
]
},
{
"id": "Section.entry:preopDiagnosis.supply",
"path": "Section.entry.supply",
"min": 0,
"max": "1",
"base": {
"path": "Entry.supply",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Supply"
}
]
},
{
"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": "should-preop-dx",
"severity": "warning",
"human": "SHOULD contain Preoperative Diagnosis",
"expression": "entry.where(act.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis'))",
"source": "http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosisSection"
}
]
},
{
"id": "Section.templateId",
"path": "Section.templateId",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "root"
},
{
"type": "value",
"path": "extension"
}
],
"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": "2.16.840.1.113883.10.20.22.2.34"
},
{
"id": "Section.templateId:section.extension",
"path": "Section.templateId.extension",
"min": 1,
"patternString": "2015-08-01"
},
{
"id": "Section.code",
"path": "Section.code",
"short": "Surgical operation note preoperative diagnosis Narrative",
"min": 1
},
{
"id": "Section.code.code",
"path": "Section.code.code",
"min": 1,
"patternCode": "10219-4"
},
{
"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
},
{
"id": "Section.entry",
"path": "Section.entry",
"slicing": {
"discriminator": [
{
"type": "profile",
"path": "act"
}
],
"rules": "open"
}
},
{
"id": "Section.entry:preopDiagnosis",
"path": "Section.entry",
"sliceName": "preopDiagnosis",
"comment": "SHOULD contain zero or one [0..1] entry (CONF:1198-10096) such that it",
"min": 0,
"max": "1"
},
{
"id": "Section.entry:preopDiagnosis.act",
"path": "Section.entry.act",
"comment": "SHALL contain exactly one [1..1] Preoperative Diagnosis (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.65:2015-08-01) (CONF:1198-15504).",
"min": 1,
"type": [
{
"code": "http://hl7.org/cda/stds/core/StructureDefinition/Act",
"profile": [
"http://hl7.org/cda/us/ccda/StructureDefinition/PreoperativeDiagnosis"
]
}
]
}
]
}
}