Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Assessment Scale Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation Version: 2.1
Draft as of 2023-09-29 Computable Name: AssessmentScaleObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.69:2022-06-01

An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), Glasgow Coma Scale (assesses coma and impaired consciousness), and WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education - a clinic-based screening and referral system developed for pediatric settings).

When an Assessment Scale Observation is contained in a Problem Observation, a Social History Observation or a Procedure instance that is Social Determinant of Health focused, that Assessment scale MAY contain assessment scale observations that represent question and answer pairs from SDOH screening instruments that are represented in LOINC. Note that guidance on the use of LOINC in assessment scales already exists in Assessment Scale Observation constraints and Assessment Scale Supporting Observations constraints.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation CDAR2.ObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
... classCode 1..1csFixed Value: OBS
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... extension 1..1stRequired Pattern: 2022-06-01
... code 1..1CD
... derivationExpr 0..1ST
... statusCode 1..1CS
.... code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ
... interpretationCode 0..*CE
.... translation 0..*CD
... author 0..*Author
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:observation, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... observation 1..1AssessmentScaleSupportingObservationBase for all types and resources
... referenceRange 0..*InfrastructureRoot
.... observationRange 1..1ObservationRange
..... text 0..1ED
...... reference 0..1TEL
....... value C0..1url4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
4515-16804errorObservation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @extension 1..1stRequired Pattern: 2022-06-01
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ST
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
.... translation 0..*CD
... author 0..*Author
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:observation, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1AssessmentScaleSupportingObservationBase for all types and resources
... referenceRange 0..*InfrastructureRoot
.... observationRange 1..1ObservationRange
..... @classCode 1..1csBinding: ActClassObservation (required)
..... text 0..1ED
...... reference 0..1TEL
....... @value C0..1url4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.interpretationCoderequiredObservationInterpretation
Observation.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Observation.referenceRange.observationRange.classCoderequiredActClassObservation

Constraints

IdGradePath(s)DetailsRequirements
4515-16804errorObservation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1bl
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @extension 1..1stRequired Pattern: 2022-06-01
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: completed
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:observation, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AssessmentScaleSupportingObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
..... @classCode 1..1csBinding: ActClassObservation (required)
..... @moodCode 0..1csBinding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... templateId 0..*II
..... code 0..1CDBinding: v3 Code System ActCode (extensible)
..... text 0..1ED
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @charset 0..1cs
...... @compression 0..1csBinding: CompressionAlgorithm (required)
...... @integrityCheck 0..1bin
...... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (required)
...... @language 0..1cs
...... @mediaType 0..1cs
...... @representation 0..1cs
...... data[x] 0..1
....... dataStringstring(st)
....... dataBase64Binarybase64Binary(bin)
...... reference 0..1TEL
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value C0..1url4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..*csBinding: AddressUse (required)
...... thumbnail 0..1ED
..... value 0..1
...... valueBL
...... valueED
...... valueST
...... valueCD
...... valueCV
...... valueCE
...... valueSC
...... valueII
...... valueTEL
...... valueAD
...... valueEN
...... valueINT
...... valueREAL
...... valuePQ
...... valueMO
...... valueTS
...... valueIVL_PQ
...... valueIVL_TS
...... valuePIVL_TS
...... valueEIVL_TS
...... valueSXPR_TS
..... interpretationCode 0..1CEBinding: ObservationInterpretation (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:templateId1.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredNullFlavor
Observation.methodCodeextensibleObservationMethod
Observation.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Observation.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV
Observation.referenceRange.observationRange.classCoderequiredActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
Observation.referenceRange.observationRange.codeextensibleActCode
Observation.referenceRange.observationRange.text.nullFlavorrequiredNullFlavor
Observation.referenceRange.observationRange.text.compressionrequiredCompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.referenceRange.observationRange.text.reference.nullFlavorrequiredNullFlavor
Observation.referenceRange.observationRange.text.reference.userequiredAddressUse
Observation.referenceRange.observationRange.interpretationCoderequiredObservationInterpretation

Constraints

IdGradePath(s)DetailsRequirements
4515-16804errorObservation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Observation

Summary

Mandatory: 9 elements (1 nested mandatory element)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension
  • The element Observation.entryRelationship is sliced based on the values of value:observation, value:typeCode

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation CDAR2.ObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
... classCode 1..1csFixed Value: OBS
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... extension 1..1stRequired Pattern: 2022-06-01
... code 1..1CD
... derivationExpr 0..1ST
... statusCode 1..1CS
.... code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ
... interpretationCode 0..*CE
.... translation 0..*CD
... author 0..*Author
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:observation, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... observation 1..1AssessmentScaleSupportingObservationBase for all types and resources
... referenceRange 0..*InfrastructureRoot
.... observationRange 1..1ObservationRange
..... text 0..1ED
...... reference 0..1TEL
....... value C0..1url4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
4515-16804errorObservation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @extension 1..1stRequired Pattern: 2022-06-01
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ST
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
.... translation 0..*CD
... author 0..*Author
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:observation, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1AssessmentScaleSupportingObservationBase for all types and resources
... referenceRange 0..*InfrastructureRoot
.... observationRange 1..1ObservationRange
..... @classCode 1..1csBinding: ActClassObservation (required)
..... text 0..1ED
...... reference 0..1TEL
....... @value C0..1url4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.interpretationCoderequiredObservationInterpretation
Observation.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Observation.referenceRange.observationRange.classCoderequiredActClassObservation

Constraints

IdGradePath(s)DetailsRequirements
4515-16804errorObservation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1bl
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @extension 1..1stRequired Pattern: 2022-06-01
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: completed
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:observation, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AssessmentScaleSupportingObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
..... @classCode 1..1csBinding: ActClassObservation (required)
..... @moodCode 0..1csBinding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... templateId 0..*II
..... code 0..1CDBinding: v3 Code System ActCode (extensible)
..... text 0..1ED
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @charset 0..1cs
...... @compression 0..1csBinding: CompressionAlgorithm (required)
...... @integrityCheck 0..1bin
...... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (required)
...... @language 0..1cs
...... @mediaType 0..1cs
...... @representation 0..1cs
...... data[x] 0..1
....... dataStringstring(st)
....... dataBase64Binarybase64Binary(bin)
...... reference 0..1TEL
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value C0..1url4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..*csBinding: AddressUse (required)
...... thumbnail 0..1ED
..... value 0..1
...... valueBL
...... valueED
...... valueST
...... valueCD
...... valueCV
...... valueCE
...... valueSC
...... valueII
...... valueTEL
...... valueAD
...... valueEN
...... valueINT
...... valueREAL
...... valuePQ
...... valueMO
...... valueTS
...... valueIVL_PQ
...... valueIVL_TS
...... valuePIVL_TS
...... valueEIVL_TS
...... valueSXPR_TS
..... interpretationCode 0..1CEBinding: ObservationInterpretation (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:templateId1.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredNullFlavor
Observation.methodCodeextensibleObservationMethod
Observation.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Observation.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV
Observation.referenceRange.observationRange.classCoderequiredActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
Observation.referenceRange.observationRange.codeextensibleActCode
Observation.referenceRange.observationRange.text.nullFlavorrequiredNullFlavor
Observation.referenceRange.observationRange.text.compressionrequiredCompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.referenceRange.observationRange.text.reference.nullFlavorrequiredNullFlavor
Observation.referenceRange.observationRange.text.reference.userequiredAddressUse
Observation.referenceRange.observationRange.interpretationCoderequiredObservationInterpretation

Constraints

IdGradePath(s)DetailsRequirements
4515-16804errorObservation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Observation

Summary

Mandatory: 9 elements (1 nested mandatory element)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension
  • The element Observation.entryRelationship is sliced based on the values of value:observation, value:typeCode

 

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