Structured Headings
Domain Message Specification

DiagnosesSection Tabular View

COCD_TP000037GB01
DiagnosesSection

This template class constrains the CDA Section class.

A section used to carry details of the diagnosis, as CDA text with a fixed title of "Diagnoses". This aligns to the appropriate document heading described in the "Standards for the clinical structure and content of patient records" document, located within the Associated Specifications tab.

Used by:
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="DOCSECT" }

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as document section.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "DOCSECT"
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as a document section event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN"
[1..1] [M] code (CV { CNE:SectionTypeSnCT } )
{ Fixed="887161000000102" }

Model Attribute Description

The HL7 attribute code uses a code from a vocabulary to code each text section in the document to provide a mechanism to allow receivers to process and reuse text sections.

Implementation in XML Instance

When using this section template then:

The Coded with Code System flavour of the coded value (CV) data type shall be used to carry this information in the XML element code as follows:

  • The XML attribute code is fixed to "887161000000102"
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"
[1..1] [M] id (II)

Model Attribute Description

The HL7 attribute id uses an identifier to identify each unique instance of a section.

Implementation in XML Instance

The Identifier Global data type flavour is used to carry the identifier in the XML element id as follows:

  • The XML attribute root shall contain a DCE UUID
[1..1] [M] templateId (II)
{ Fixed="COCD_TP000037GB01#DiagnosesSection" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP000037GB01#DiagnosesSection"
[1..1] [M] text (ED)

Model Attribute Description

The HL7 attribute text is used for the CDA markup for this section.

Implementation in XML Instance

The XML element text uses the ED data type and should be populated with the CDA structured text representation of the information for this section as permitted by the CDA NarrativeBlock schema. This schema is named NarrativeBlock.xsd and located in the "dt" folder.

[1..1] [M] title (ST)
{ Fixed="Diagnoses" }

Model Attribute Description

The HL7 attribute title allows each section to have a heading.

Implementation in XML Instance

  • The XML element title is fixed to "Diagnoses"
[0..1] author

This template class constrains the CDA author class.

The author of this diagnosis must be included if the author is different to the document (inherited) author.

If there is no known author for the information held on the source system then:

  • The information may be included and the document author will be deemed to be the author (by inheritance). The author should be asked to decide whether this is acceptable or not
  • If the document author does not want to be considered as the author of the information then information must not be included in the document
[1..1] [M] typeCode (CS { CNE: ParticipationType } )
{ Fixed="AUT" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe this class as an author participation.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "AUT"
[1..1] [M] contextControlCode (CS { CNE: ContextControl } )
{ Fixed="OP" }

Model Attribute Description

The HL7 attribute contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent section are conducted across to the child section (also associated with the child section). This set of codes also determine how these participations conduct.

The conduction can only take place if the contextConductionInd is set to "true".

The value of this attribute is fixed in the HL7 model to "OP":

  • "O" (Overriding) - the author replaces any author that has been conducted from any previous acts
  • "P" (Propagating) - the author is conducted to all child acts where the contextConductionInd is set to "true"

Implementation in XML Instance

  • The XML attribute contextControlCode shall contain the value "OP"
[1..1] [M] contentId (II) { "NPFIT-300001#Role" }

Model Attribute Description

The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model.


Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element contentId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The XML attribute extension shall contain one of the allowed template artefact identifiers
[1..1] [M] functionCode (CV { CNE:AuthorFunctionType } )
{ Fixed="OA" }

Model Attribute Description

The HL7 attribute functionCode uses a code from the vocabulary AuthorFunctionType to describe the function of the author.

Implementation in XML Instance

The Coded Plain flavour of Coded Value (CV) datatype shall be used to carry this information in the XML element functionCode as follows:

  • The XML attribute code shall contain the value "OA"
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.178"
  • The XML attribute displayName will contain the value "Originating Author"
[1..1] [M] templateId (II)
{ Fixed="COCD_TP000037GB01#author" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP000037GB01#author"
[1..1] [R] time (TS)

Model Attribute Description

The HL7 attribute author time is used to indicate when the person authored the CDA document.

Implementation in XML Instance

The XML attribute value of the XML element time, shall be populated with a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

  • yyyy is the year
  • mm is the month
  • dd is the day
  • hh is the hour
  • mm is the minutes
  • ss is the seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off to when the sending system does not record to this accuracy. When hours are present, the time zone offset must also be present.

Where no time is recorded or available then:

  • The XML attribute nullFlavor of the XML element time shall contain the value "UNK"
[1..1] participant (AuthorChoice)

A link to the choice of author templates.

[0..*] entry

This template class constrains the CDA entry class.

This class is an entry. It links the CDA section to the choice of CDA coded entries.

[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="COMP" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe this class as a component.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "COMP"
[1..1] [M] contextConductionInd (BL)
{ Fixed="true" }

Model Attribute Description

The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent section is conducted across to the child section (also associated with the child section).

Implementation in XML Instance

  • The XML attribute contextConductionInd is fixed to "true"
[1..1] [M] contentId (II) { "NPFIT-300003#Act" }

Model Attribute Description

The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model.


Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element contentId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The XML attribute extension shall contain one of the allowed template artefact identifiers.

[1..1] [M] templateId (II)
{ Fixed="COCD_TP000037GB01#entry" }

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP000037GB01#entry"

[1..1] codedDiagnosesChoice (CodedDiagnosesChoice)

A link to the coded diagnoses choice.

AuthorChoice

An abstract placeholder for the choice of author for the diagnoses section.

Used by: DiagnosesSection
[1..1] : Template

A link to the choice of author templates.

CodedDiagnosesChoice

The coded diagnoses choice.

Used by: DiagnosesSection
[1..1] : Template1

A link to the choice of coded diagnoses.