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FHIR IG Statistics: StructureDefinition/2.16.840.1.113883.10.20.6.1.2

Packagehl7.cda.us.ccdar2dot2
TypeStructureDefinition
Id2.16.840.1.113883.10.20.6.1.2
FHIR VersionR4
Sourcehttp://hl7.org/cda/us/ccda/https://build.fhir.org/ig/HL7/CDA-ccda-2.2/StructureDefinition-2.16.840.1.113883.10.20.6.1.2.html
URLhttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.1.2
Version2.2
Statusactive
Date2022-05-13T15:50:12+00:00
NameFindingsSectionDIR
TitleFindings Section (DIR)
Realmus
Authorityhl7
DescriptionThe Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.
TypeSection
Kindresource

Resources that use this resource

StructureDefinition
2.16.840.1.113883.10.20.22.1.5Diagnostic Imaging Report

Resources that this resource uses

No resources found


Narrative

Note: links and images are rebased to the (stated) source

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section I1..1CDAR2.Section81-8532: This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532).
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.1.2

doco Documentation for this format

Source

{
  "resourceType": "StructureDefinition",
  "id": "2.16.840.1.113883.10.20.6.1.2",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.1.2",
  "identifier": [
    {
      "value": "urn:oid:2.16.840.1.113883.10.20.6.1.2"
    }
  ],
  "version": "2.2",
  "name": "FindingsSectionDIR",
  "title": "Findings Section (DIR)",
  "status": "active",
  "date": "2022-05-13T15:50:12+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 Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "US"
        }
      ]
    }
  ],
  "fhirVersion": "4.0.1",
  "kind": "resource",
  "abstract": false,
  "type": "Section",
  "baseDefinition": "http://hl7.org/fhir/cda/StructureDefinition/Section",
  "derivation": "constraint",
  "snapshot": {
    "element": [
      {
        "id": "Section",
        "path": "Section",
        "min": 1,
        "max": "1",
        "base": {
          "path": "Base",
          "min": 0,
          "max": "*"
        },
        "constraint": [
          {
            "key": "81-8532",
            "severity": "warning",
            "human": "This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections.  However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532)."
          }
        ],
        "isModifier": false
      },
      {
        "id": "Section.ID",
        "path": "Section.ID",
        "representation": [
          "xmlAttr"
        ],
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.ID",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "Section.nullFlavor",
        "path": "Section.nullFlavor",
        "representation": [
          "xmlAttr"
        ],
        "min": 0,
        "max": "1",
        "base": {
          "path": "ANY.nullFlavor",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-NullFlavor"
        }
      },
      {
        "id": "Section.classCode",
        "path": "Section.classCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.classCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "DOCSECT",
        "fixedCode": "DOCSECT",
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer"
        }
      },
      {
        "id": "Section.moodCode",
        "path": "Section.moodCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.moodCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "EVN",
        "fixedCode": "EVN",
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-ActMood"
        }
      },
      {
        "id": "Section.templateId",
        "path": "Section.templateId",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "root"
            }
          ],
          "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": 0,
        "max": "*",
        "base": {
          "path": "Section.templateId",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id": "Section.templateId:primary",
        "path": "Section.templateId",
        "sliceName": "primary",
        "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",
        "requirements": "SHALL contain exactly one [1..1] templateId (CONF:81-8531) such that it",
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.templateId",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id": "Section.templateId:primary.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",
        "base": {
          "path": "ANY.nullFlavor",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-NullFlavor"
        }
      },
      {
        "id": "Section.templateId:primary.assigningAuthorityName",
        "path": "Section.templateId.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"
          }
        ]
      },
      {
        "id": "Section.templateId:primary.displayable",
        "path": "Section.templateId.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"
          }
        ]
      },
      {
        "id": "Section.templateId:primary.root",
        "path": "Section.templateId.root",
        "representation": [
          "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.",
        "requirements": "SHALL contain exactly one [1..1] @root=\"2.16.840.1.113883.10.20.6.1.2\" (CONF:81-10456).",
        "min": 1,
        "max": "1",
        "base": {
          "path": "II.root",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "string"
          }
        ],
        "patternString": "2.16.840.1.113883.10.20.6.1.2"
      },
      {
        "id": "Section.templateId:primary.extension",
        "path": "Section.templateId.extension",
        "representation": [
          "xmlAttr"
        ],
        "label": "Extension",
        "definition": "A character string as a unique identifier within the scope of the identifier root.",
        "min": 0,
        "max": "1",
        "base": {
          "path": "II.extension",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "Section.id",
        "path": "Section.id",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.id",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/II"
          }
        ]
      },
      {
        "id": "Section.code",
        "path": "Section.code",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.code",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/CE"
          }
        ],
        "binding": {
          "strength": "extensible",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-DocumentSectionType"
        }
      },
      {
        "id": "Section.title",
        "path": "Section.title",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.title",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/ST"
          }
        ]
      },
      {
        "id": "Section.text",
        "path": "Section.text",
        "representation": [
          "cdaText"
        ],
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.text",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "xhtml"
          }
        ],
        "mustSupport": true
      },
      {
        "id": "Section.confidentialityCode",
        "path": "Section.confidentialityCode",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.confidentialityCode",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/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/fhir/cda/StructureDefinition/CS"
          }
        ],
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-HumanLanguage"
        }
      },
      {
        "id": "Section.subject",
        "path": "Section.subject",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.subject",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "Element"
          }
        ]
      },
      {
        "id": "Section.subject.typeCode",
        "path": "Section.subject.typeCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.subject.typeCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "SBJ",
        "fixedCode": "SBJ",
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject"
        }
      },
      {
        "id": "Section.subject.contextControlCode",
        "path": "Section.subject.contextControlCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.subject.contextControlCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "OP",
        "fixedCode": "OP",
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-ContextControl"
        }
      },
      {
        "id": "Section.subject.awarenessCode",
        "path": "Section.subject.awarenessCode",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.subject.awarenessCode",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/CE"
          }
        ],
        "binding": {
          "strength": "extensible",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-TargetAwareness"
        }
      },
      {
        "id": "Section.subject.relatedSubject",
        "path": "Section.subject.relatedSubject",
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.subject.relatedSubject",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/RelatedSubject"
          }
        ]
      },
      {
        "id": "Section.author",
        "path": "Section.author",
        "min": 0,
        "max": "*",
        "base": {
          "path": "Section.author",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Author"
          }
        ]
      },
      {
        "id": "Section.informant",
        "path": "Section.informant",
        "min": 0,
        "max": "*",
        "base": {
          "path": "Section.informant",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "Element"
          }
        ]
      },
      {
        "id": "Section.informant.typeCode",
        "path": "Section.informant.typeCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.informant.typeCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "INF",
        "fixedCode": "INF",
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-ParticipationInformationGenerator"
        }
      },
      {
        "id": "Section.informant.contextControlCode",
        "path": "Section.informant.contextControlCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.informant.contextControlCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "OP",
        "fixedCode": "OP",
        "binding": {
          "strength": "required",
          "valueSet": "http://terminology.hl7.org/ValueSet/v3-ContextControl"
        }
      },
      {
        "id": "Section.informant.assignedEntity",
        "path": "Section.informant.assignedEntity",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.informant.assignedEntity",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/AssignedEntity"
          }
        ]
      },
      {
        "id": "Section.informant.relatedEntity",
        "path": "Section.informant.relatedEntity",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.informant.relatedEntity",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/RelatedEntity"
          }
        ]
      },
      {
        "id": "Section.entry",
        "path": "Section.entry",
        "min": 0,
        "max": "*",
        "base": {
          "path": "Section.entry",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "Element"
          }
        ],
        "constraint": [
          {
            "key": "only-one-statement",
            "severity": "error",
            "human": "SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.",
            "expression": "(observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1",
            "source": "http://hl7.org/fhir/cda/StructureDefinition/Section"
          }
        ]
      },
      {
        "id": "Section.entry.typeCode",
        "path": "Section.entry.typeCode",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.entry.typeCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "COMP"
      },
      {
        "id": "Section.entry.contextConductionInd",
        "path": "Section.entry.contextConductionInd",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.entry.contextConductionInd",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "boolean"
          }
        ],
        "defaultValueBoolean": true
      },
      {
        "id": "Section.entry.observation",
        "path": "Section.entry.observation",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.observation",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Observation"
          }
        ]
      },
      {
        "id": "Section.entry.regionOfInterest",
        "path": "Section.entry.regionOfInterest",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.regionOfInterest",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest"
          }
        ]
      },
      {
        "id": "Section.entry.observationMedia",
        "path": "Section.entry.observationMedia",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.observationMedia",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/ObservationMedia"
          }
        ]
      },
      {
        "id": "Section.entry.substanceAdministration",
        "path": "Section.entry.substanceAdministration",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.substanceAdministration",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration"
          }
        ]
      },
      {
        "id": "Section.entry.supply",
        "path": "Section.entry.supply",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.supply",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Supply"
          }
        ]
      },
      {
        "id": "Section.entry.procedure",
        "path": "Section.entry.procedure",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.procedure",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Procedure"
          }
        ]
      },
      {
        "id": "Section.entry.encounter",
        "path": "Section.entry.encounter",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.encounter",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Encounter"
          }
        ]
      },
      {
        "id": "Section.entry.organizer",
        "path": "Section.entry.organizer",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.organizer",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Organizer"
          }
        ]
      },
      {
        "id": "Section.entry.act",
        "path": "Section.entry.act",
        "min": 0,
        "max": "1",
        "base": {
          "path": "Section.entry.act",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "http://hl7.org/fhir/cda/StructureDefinition/Act"
          }
        ]
      },
      {
        "id": "Section.component",
        "path": "Section.component",
        "min": 0,
        "max": "*",
        "base": {
          "path": "Section.component",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "Element"
          }
        ]
      },
      {
        "id": "Section.component.typeCode",
        "path": "Section.component.typeCode",
        "representation": [
          "xmlAttr"
        ],
        "definition": "Drawn from concept domain DocumentSectionType",
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.component.typeCode",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "code"
          }
        ],
        "defaultValueCode": "COMP",
        "fixedCode": "COMP"
      },
      {
        "id": "Section.component.contextConductionInd",
        "path": "Section.component.contextConductionInd",
        "representation": [
          "xmlAttr"
        ],
        "min": 1,
        "max": "1",
        "base": {
          "path": "Section.component.contextConductionInd",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "boolean"
          }
        ],
        "defaultValueBoolean": 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/fhir/cda/StructureDefinition/Section"
          }
        ]
      }
    ]
  },
  "differential": {
    "element": [
      {
        "id": "Section",
        "path": "Section",
        "constraint": [
          {
            "key": "81-8532",
            "severity": "warning",
            "human": "This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections.  However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532)."
          }
        ]
      },
      {
        "id": "Section.templateId",
        "path": "Section.templateId",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "root"
            }
          ],
          "rules": "open"
        }
      },
      {
        "id": "Section.templateId:primary",
        "path": "Section.templateId",
        "sliceName": "primary",
        "requirements": "SHALL contain exactly one [1..1] templateId (CONF:81-8531) such that it",
        "min": 1,
        "max": "1"
      },
      {
        "id": "Section.templateId:primary.root",
        "path": "Section.templateId.root",
        "requirements": "SHALL contain exactly one [1..1] @root=\"2.16.840.1.113883.10.20.6.1.2\" (CONF:81-10456).",
        "min": 1,
        "max": "1",
        "patternString": "2.16.840.1.113883.10.20.6.1.2"
      }
    ]
  }
}