Section Matrix

Section Matrix

Section

ConsultationNote

2.16.840.1.113883.10.20.22.1.4

ContinuityOfCareDocument

2.16.840.1.113883.10.20.22.1.2

DiagnosticImagingReport

2.16.840.1.113883.10.20.22.1.5

DischargeSummary

2.16.840.1.113883.10.20.22.1.8

GeneralHeaderConstraints

2.16.840.1.113883.10.20.22.1.1

HistoryAndPhysicalNote

2.16.840.1.113883.10.20.22.1.3

OperativeNote

2.16.840.1.113883.10.20.22.1.7

ProcedureNote

2.16.840.1.113883.10.20.22.1.6

ProgressNote

2.16.840.1.113883.10.20.22.1.9

UnstructuredDocument

2.16.840.1.113883.10.20.21.1.10

AdvanceDirectivesSection (2.16.840.1.113883.10.20.22.2.21.1) O (MAY) (CONF:9455)
AdvanceDirectivesSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.21)
AllergiesSection (2.16.840.1.113883.10.20.22.2.6.1) R (SHALL) (CONF:9445)
AllergiesSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.6) O (MAY) (CONF:9507) R (SHALL) (CONF:9542) R (SHALL) (CONF:9602) O (MAY) (CONF:9809) O (MAY) (CONF:8773)
AnesthesiaSection (2.16.840.1.113883.10.20.22.2.25) R (SHALL) (CONF:9883) O (MAY) (CONF:9811)
AssessmentAndPlanSection (2.16.840.1.113883.10.20.22.2.9) O (MAY) (CONF:9491) O (MAY) (CONF:9987) O (MAY) (CONF:9649) O (MAY) (CONF:8774)
AssessmentSection (2.16.840.1.113883.10.20.22.2.8) O (MAY) (CONF:9487) O (MAY) (CONF:9605) O (MAY) (CONF:9645) O (MAY) (CONF:8776)
ChiefComplaintAndReasonForVisitSection (2.16.840.1.113883.10.20.22.2.13) O (MAY) (CONF:10029) O (MAY) (CONF:9556) O (MAY) (CONF:9613) O (MAY) (CONF:9815)
ChiefComplaintSection (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) O (MAY) (CONF:9509) O (MAY) (CONF:9554) O (MAY) (CONF:9611) O (MAY) (CONF:9813) O (MAY) (CONF:8772)
ComplicationsSection (2.16.840.1.113883.10.20.22.2.37) R (SHALL) (CONF:9885) R (SHALL) (CONF:9802)
DICOMObjectCatalogSection (2.16.840.1.113883.10.20.6.1.1) R2 (SHOULD) (CONF:15141)
DischargeDietSection (1.3.6.1.4.1.19376.1.5.3.1.3.33) O (MAY) (CONF:9558)
EncountersSection (2.16.840.1.113883.10.20.22.2.22.1) O (MAY) (CONF:9457)
EncountersSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.22)
FamilyHistorySection (2.16.840.1.113883.10.20.22.2.15) O (MAY) (CONF:9513) O (MAY) (CONF:9459) O (MAY) (CONF:9560) R (SHALL) (CONF:9615) O (MAY) (CONF:9817)
FindingsSection (2.16.840.1.113883.10.20.6.1.2) R (SHALL) (CONF:8776)
FunctionalStatusSection (2.16.840.1.113883.10.20.22.2.14) O (MAY) (CONF:9461) O (MAY) (CONF:9562)
GeneralStatusSection (2.16.840.1.113883.10.20.2.5) O (MAY) (CONF:9515) R (SHALL) (CONF:9617)
HistoryOfPastIllnessSection (2.16.840.1.113883.10.20.22.2.20) O (MAY) (CONF:9517) O (MAY) (CONF:9564) R (SHALL) (CONF:9619) O (MAY) (CONF:9819)
HistoryOfPresentIllnessSection (1.3.6.1.4.1.19376.1.5.3.1.3.4) R (SHALL) (CONF:9493) O (MAY) (CONF:9566) R2 (SHOULD) (CONF:9621) O (MAY) (CONF:9821)
HospitalAdmissionDiagnosisSection (2.16.840.1.113883.10.20.22.2.43) R (SHALL) (CONF:9928)
HospitalAdmissionMedicationsSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.44) O (MAY) (CONF:10111)
HospitalConsultationsSection (2.16.840.1.113883.10.20.22.2.42) O (MAY) (CONF:9924)
HospitalCourseSection (1.3.6.1.4.1.19376.1.5.3.1.3.5) R (SHALL) (CONF:9544)
HospitalDischargeDiagnosisSection (2.16.840.1.113883.10.20.22.2.24) R (SHALL) (CONF:9546)
HospitalDischargeInstructionsSection (2.16.840.1.113883.10.20.22.2.41) O (MAY) (CONF:9926)
HospitalDischargeMedicationsSection (2.16.840.1.113883.10.20.22.2.11.1)
HospitalDischargeMedicationsSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.11) R (SHALL) (CONF:9548)
HospitalDischargePhysicalSection (1.3.6.1.4.1.19376.1.5.3.1.3.26) O (MAY) (CONF:9568)
HospitalDischargeStudiesSummarySection (2.16.840.1.113883.10.20.22.2.16) O (MAY) (CONF:9570)
ImmunizationsSection (2.16.840.1.113883.10.20.22.2.2.1) O (MAY) (CONF:9519)
ImmunizationsSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.2) O (MAY) (CONF:9463) O (MAY) (CONF:9572) O (MAY) (CONF:9637)
InstructionsSection (2.16.840.1.113883.10.20.22.2.45) O (MAY) (CONF:16807) O (MAY) (CONF:16806)
InterventionsSection (2.16.840.1.113883.10.20.21.2.3) O (MAY) (CONF:8778)
MedicalEquipmentSection (2.16.840.1.113883.10.20.22.2.23) O (MAY) (CONF:9466)
MedicalHistorySection (2.16.840.1.113883.10.20.22.2.39) O (MAY) (CONF:9823)
MedicationsAdministeredSection (2.16.840.1.113883.10.20.22.2.38) O (MAY) (CONF:9827)
MedicationsSection (2.16.840.1.113883.10.20.22.2.1.1) R (SHALL) (CONF:9447)
MedicationsSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.1) O (MAY) (CONF:9521)) R (SHALL) (CONF:9623) O (MAY) (CONF:9825) O (MAY) (CONF:8771)
ObjectiveSection (2.16.840.1.113883.10.20.21.2.1) O (MAY) (CONF:8770)
OperativeNoteFluidSection (2.16.840.1.113883.10.20.7.12) O (MAY) (CONF:9900)
OperativeNoteSurgicalProcedureSection (2.16.840.1.113883.10.20.7.14) O (MAY) (CONF:9902)
PayersSection (2.16.840.1.113883.10.20.22.2.18) O (MAY) (CONF:9468)
PhysicalExamSection (2.16.840.1.113883.10.20.2.10) R2 (SHOULD) (CONF:9495) R (SHALL) (CONF:9625) O (MAY) (CONF:9829) O (MAY) (CONF:8780)
PlanOfCareSection (2.16.840.1.113883.10.20.22.2.10) O (MAY) (CONF:9489) O (MAY) (CONF:9470) R (SHALL) (CONF:9550) O (MAY) (CONF:9607) O (MAY) (CONF:9904) O (MAY) (CONF:9647) O (MAY) (CONF:8775)
PlannedProcedureSection (2.16.840.1.113883.10.20.22.2.30) O (MAY) (CONF:9906) O (MAY) (CONF:9831)
PostoperativeDiagnosisSection (2.16.840.1.113883.10.20.22.2.35) R (SHALL) (CONF:9913)
PostprocedureDiagnosisSection (2.16.840.1.113883.10.20.22.2.36) R (SHALL) (CONF:9850)
PreoperativeDiagnosisSection (2.16.840.1.113883.10.20.22.2.34) R (SHALL) (CONF:9888)
ProblemSection (2.16.840.1.113883.10.20.22.2.5.1) R (SHALL) (CONF:9449)
ProblemSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.5) O (MAY) (CONF:9523) O (MAY) (CONF:9574) O (MAY) (CONF:9639) O (MAY) (CONF:8786)
ProcedureDescriptionSection (2.16.840.1.113883.10.20.22.2.27) R (SHALL) (CONF:9896) R (SHALL) (CONF:9805)
ProcedureDispositionSection (2.16.840.1.113883.10.20.18.2.12) O (MAY) (CONF:9908) O (MAY) (CONF:9833)
ProcedureEstimatedBloodLossSection (2.16.840.1.113883.10.20.18.2.9) R (SHALL) (CONF:9890) O (MAY) (CONF:9835)
ProcedureFindingsSection (2.16.840.1.113883.10.20.22.2.28) R (SHALL) (CONF:9892) O (MAY) (CONF:9837)
ProcedureImplantsSection (2.16.840.1.113883.10.20.22.2.40) O (MAY) (CONF:9898) O (MAY) (CONF:9839)
ProcedureIndicationsSection (2.16.840.1.113883.10.20.22.2.29) O (MAY) (CONF:9910) R (SHALL) (CONF:9807)
ProcedureSpecimensTakenSection (2.16.840.1.113883.10.20.22.2.31) R (SHALL) (CONF:9894) O (MAY) (CONF:9841)
ProceduresSection (2.16.840.1.113883.10.20.22.2.7.1) R (SHALL) (CONF:9451)
ProceduresSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.7) O (MAY) (CONF:9525) O (MAY) (CONF:9576) O (MAY) (CONF:9641) O (MAY) (CONF:9843)
ReasonForReferralSection (1.3.6.1.4.1.19376.1.5.3.1.3.1) O (MAY) (CONF:9498)
ReasonForVisitSection (2.16.840.1.113883.10.20.22.2.12) O (MAY) (CONF:9500) O (MAY) (CONF:9578) O (MAY) (CONF:9627) O (MAY) (CONF:9845)
ResultsSection (2.16.840.1.113883.10.20.22.2.3.1) R (SHALL) (CONF:9453)
ResultsSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.3) O (MAY) (CONF:9527) R (SHALL) (CONF:9629) O (MAY) (CONF:8782)
ReviewOfSystemsSection (1.3.6.1.4.1.19376.1.5.3.1.3.18) O (MAY) (CONF:9529) O (MAY) (CONF:9580) R (SHALL) (CONF:9631) O (MAY) (CONF:9847) O (MAY) (CONF:8788)
SocialHistorySection (2.16.840.1.113883.10.20.22.2.17) O (MAY) (CONF:9531) O (MAY) (CONF:9472) O (MAY) (CONF:9582) R (SHALL) (CONF:9633) O (MAY) (CONF:9849)
SubjectiveSection (2.16.840.1.113883.10.20.21.2.2) O (MAY) (CONF:8790)
SurgicalDrainsSection (2.16.840.1.113883.10.20.7.13) O (MAY) (CONF:9912)
VitalSignsSection (2.16.840.1.113883.10.20.22.2.4.1)
VitalSignsSectionEntriesOptional (2.16.840.1.113883.10.20.22.2.4) O (MAY) (CONF:9533) O (MAY) (CONF:9474) O (MAY) (CONF:9584) R (SHALL) (CONF:9635) O (MAY) (CONF:8784)