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| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/GeneralStatusSection | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: GeneralStatusSection | |||
| Other Identifiers: OID:2.16.840.1.113883.10.20.2.5 | ||||
The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
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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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.5 | |
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0..0 | |||
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1..1 | CE | Physical findings of General status Narrative | |
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1..1 | cs | Required Pattern: 10210-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
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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) | |
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.5 | |
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1..1 | CE | Physical findings of General status Narrative Binding: DocumentSectionType (example) | |
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1..1 | cs | Required Pattern: 10210-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.5 | |
![]() ![]() ![]() ![]() |
0..0 | |||
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1..1 | CE | Physical findings of General status Narrative | |
![]() ![]() ![]() |
1..1 | cs | Required Pattern: 10210-3 | |
![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
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) | |
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1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() |
1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.5 | |
![]() ![]() |
1..1 | CE | Physical findings of General status Narrative Binding: DocumentSectionType (example) | |
![]() ![]() ![]() |
1..1 | cs | Required Pattern: 10210-3 | |
![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
Snapshot View
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |