Consolidated CDA Release 2.1 StructureDefinition Publication
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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: Longitudinal Care Wound Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/LongitudinalCareWoundObservation Version: 2.1
Draft as of 2023-09-29 Computable Name: LongitudinalCareWoundObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.114:2015-08-01

This template represents acquired or surgical wounds and is not intended to encompass all wound types. The template applies to wounds such as pressure ulcers, surgical incisions, and deep tissue injury wounds. Information in this template may include information about the wound measurements characteristics.

Usage:

Formal Views of Profile Content

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

This structure is derived from ProblemObservation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation ProblemObservationXML 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, moodCode, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
... classCode 1..1cs
... moodCode 1..1cs
... templateId 2..*II
.... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.114
.... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CD
.... code 1..1csRequired Pattern: ASSERTION
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.4
... value 1..1CDBinding: Wound Type (preferred)
... targetSiteCode 0..1CDBinding: Body Site Value Set (preferred)
.... qualifier 0..*CRIf targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
..... name 1..1CV
...... code 1..1csRequired Pattern: 272741003
...... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... value 1..1CD
...... code 1..1csBinding: TargetSite Qualifiers (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... entryRelationship 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
... entryRelationship:woundMeasurementObservation 0..*EntryRelationship
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1WoundMeasurementObservationBase for all types and resources
... entryRelationship:woundCharacteristic 0..*EntryRelationship
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1WoundCharacteristicBase for all types and resources
... entryRelationship:numberofPressureUlcersObservation 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1NumberofPressureUlcersObservationBase for all types and resources
... entryRelationship:highestPressureUlcerStage 0..1EntryRelationship
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1HighestPressureUlcerStageBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.valuepreferredWound Type
Observation.targetSiteCodepreferredBody Site Value Set
Observation.targetSiteCode.qualifier.value.codepreferredTargetSite Qualifiers
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1ProblemObservationXML 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, moodCode, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.4
..... @extension 1..1stRequired Pattern: 2015-08-01
.... templateId:secondary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.114
..... @extension 1..1stRequired Pattern: 2015-08-01
... code C1..1CDBinding: Problem Type (SNOMEDCT) (preferred)
.... @code 1..1csRequired Pattern: ASSERTION
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.4
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TSIf the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
.... low 1..1IVXB_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
... value 1..1CDBinding: Wound Type (preferred)
.... Slices for translation 0..*CDSlice: Unordered, Open by value:code
..... translation:alt 0..*CD
... targetSiteCode 0..1CDBinding: Body Site Value Set (preferred)
.... qualifier 0..*CRIf targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
..... name 1..1CV
...... @code 1..1csRequired Pattern: 272741003
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... value 1..1CD
...... @code 1..1csBinding: TargetSite Qualifiers (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
Slice: Unordered, Open by profile:observation
.... entryRelationship:age 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... observation 1..1AgeObservationBase for all types and resources
.... entryRelationship:prognosis 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation 1..1PrognosisObservationBase for all types and resources
.... entryRelationship:priority 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:status 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation 1..1ProblemStatusBase for all types and resources
.... entryRelationship:woundMeasurementObservation 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1WoundMeasurementObservationBase for all types and resources
.... entryRelationship:woundCharacteristic 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1WoundCharacteristicBase for all types and resources
.... entryRelationship:numberofPressureUlcersObservation 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1NumberofPressureUlcersObservationBase for all types and resources
.... entryRelationship:highestPressureUlcerStage 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1HighestPressureUlcerStageBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codepreferredProblem Type (SNOMEDCT)
Observation.statusCoderequiredActStatus
Observation.valuepreferredWound Type
Observation.targetSiteCodepreferredBody Site Value Set
Observation.targetSiteCode.qualifier.value.codepreferredTargetSite Qualifiers
Observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
Observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:woundCharacteristic.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.typeCoderequiredFixed Value: COMP

Constraints

IdGradePath(s)DetailsRequirements
1198-32950errorObservation.codeIf code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1ProblemObservationXML 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, moodCode, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1blThe negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.4
..... @extension 1..1stRequired Pattern: 2015-08-01
.... templateId:secondary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.114
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 1..*II
... code C1..1CDBinding: Problem Type (SNOMEDCT) (preferred)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: ASSERTION
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.4
.... @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
.... qualifier 0..*CR
.... translation 0..*CD
... 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_TSIf the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 1..1IVXB_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Wound Type (preferred)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1csA negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
.... @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
.... qualifier 0..*CRThe observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML.
.... Slices for translation 0..*CDSlice: Unordered, Open by value:code
..... translation:alt 0..*CD
...... @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
...... qualifier 0..*CR
...... translation 0..*CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..1CDBinding: Body Site Value Set (preferred)
.... @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
.... qualifier 0..*CRIf targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @inverted 0..1bn
..... name 1..1CV
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @code 1..1csRequired Pattern: 272741003
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
...... @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
..... value 1..1CD
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @code 1..1csBinding: TargetSite Qualifiers (preferred)
...... @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
...... qualifier 0..*CR
...... translation 0..*CD
.... translation 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
Slice: Unordered, Open by profile:observation
.... entryRelationship:age 0..1EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AgeObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:prognosis 0..1EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1PrognosisObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:priority 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1PriorityPreferenceBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:status 0..1EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1ProblemStatusBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:woundMeasurementObservation 0..*EntryRelationship
..... @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..1WoundMeasurementObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:woundCharacteristic 0..*EntryRelationship
..... @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..1WoundCharacteristicBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:numberofPressureUlcersObservation 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
..... @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..1NumberofPressureUlcersObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:highestPressureUlcerStage 0..1EntryRelationship
..... @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..1HighestPressureUlcerStageBase 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.templateId:secondary.nullFlavorrequiredNullFlavor
Observation.codepreferredProblem Type (SNOMEDCT)
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.effectiveTime.operatorrequiredSetOperator
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuepreferredWound Type
Observation.value.nullFlavorrequiredNullFlavor
Observation.value.translation:alt.nullFlavorrequiredNullFlavor
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCodepreferredBody Site Value Set
Observation.targetSiteCode.nullFlavorrequiredNullFlavor
Observation.targetSiteCode.qualifier.nullFlavorrequiredNullFlavor
Observation.targetSiteCode.qualifier.name.nullFlavorrequiredNullFlavor
Observation.targetSiteCode.qualifier.value.nullFlavorrequiredNullFlavor
Observation.targetSiteCode.qualifier.value.codepreferredTargetSite Qualifiers
Observation.entryRelationship:age.nullFlavorrequiredNullFlavor
Observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
Observation.entryRelationship:prognosis.nullFlavorrequiredNullFlavor
Observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:priority.nullFlavorrequiredNullFlavor
Observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:status.nullFlavorrequiredNullFlavor
Observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.nullFlavorrequiredNullFlavor
Observation.entryRelationship:woundMeasurementObservation.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:woundCharacteristic.nullFlavorrequiredNullFlavor
Observation.entryRelationship:woundCharacteristic.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.nullFlavorrequiredNullFlavor
Observation.entryRelationship:numberofPressureUlcersObservation.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.nullFlavorrequiredNullFlavor
Observation.entryRelationship:highestPressureUlcerStage.typeCoderequiredFixed Value: COMP
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
1198-32950errorObservation.codeIf code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Differential View

This structure is derived from ProblemObservation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation ProblemObservationXML 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, moodCode, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
... classCode 1..1cs
... moodCode 1..1cs
... templateId 2..*II
.... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.114
.... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CD
.... code 1..1csRequired Pattern: ASSERTION
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.4
... value 1..1CDBinding: Wound Type (preferred)
... targetSiteCode 0..1CDBinding: Body Site Value Set (preferred)
.... qualifier 0..*CRIf targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
..... name 1..1CV
...... code 1..1csRequired Pattern: 272741003
...... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... value 1..1CD
...... code 1..1csBinding: TargetSite Qualifiers (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... entryRelationship 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
... entryRelationship:woundMeasurementObservation 0..*EntryRelationship
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1WoundMeasurementObservationBase for all types and resources
... entryRelationship:woundCharacteristic 0..*EntryRelationship
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1WoundCharacteristicBase for all types and resources
... entryRelationship:numberofPressureUlcersObservation 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1NumberofPressureUlcersObservationBase for all types and resources
... entryRelationship:highestPressureUlcerStage 0..1EntryRelationship
.... typeCode 1..1csFixed Value: COMP
.... observation 1..1HighestPressureUlcerStageBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.valuepreferredWound Type
Observation.targetSiteCodepreferredBody Site Value Set
Observation.targetSiteCode.qualifier.value.codepreferredTargetSite Qualifiers

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1ProblemObservationXML 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, moodCode, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.4
..... @extension 1..1stRequired Pattern: 2015-08-01
.... templateId:secondary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.114
..... @extension 1..1stRequired Pattern: 2015-08-01
... code C1..1CDBinding: Problem Type (SNOMEDCT) (preferred)
.... @code 1..1csRequired Pattern: ASSERTION
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.4
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TSIf the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
.... low 1..1IVXB_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
... value 1..1CDBinding: Wound Type (preferred)
.... Slices for translation 0..*CDSlice: Unordered, Open by value:code
..... translation:alt 0..*CD
... targetSiteCode 0..1CDBinding: Body Site Value Set (preferred)
.... qualifier 0..*CRIf targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
..... name 1..1CV
...... @code 1..1csRequired Pattern: 272741003
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... value 1..1CD
...... @code 1..1csBinding: TargetSite Qualifiers (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
Slice: Unordered, Open by profile:observation
.... entryRelationship:age 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... observation 1..1AgeObservationBase for all types and resources
.... entryRelationship:prognosis 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation 1..1PrognosisObservationBase for all types and resources
.... entryRelationship:priority 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:status 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation 1..1ProblemStatusBase for all types and resources
.... entryRelationship:woundMeasurementObservation 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1WoundMeasurementObservationBase for all types and resources
.... entryRelationship:woundCharacteristic 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1WoundCharacteristicBase for all types and resources
.... entryRelationship:numberofPressureUlcersObservation 0..*EntryRelationshipWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1NumberofPressureUlcersObservationBase for all types and resources
.... entryRelationship:highestPressureUlcerStage 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1HighestPressureUlcerStageBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codepreferredProblem Type (SNOMEDCT)
Observation.statusCoderequiredActStatus
Observation.valuepreferredWound Type
Observation.targetSiteCodepreferredBody Site Value Set
Observation.targetSiteCode.qualifier.value.codepreferredTargetSite Qualifiers
Observation.entryRelationship:age.typeCoderequiredFixed Value: SUBJ
Observation.entryRelationship:prognosis.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:priority.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:status.typeCoderequiredFixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:woundCharacteristic.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.typeCoderequiredFixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.typeCoderequiredFixed Value: COMP

Constraints

IdGradePath(s)DetailsRequirements
1198-32950errorObservation.codeIf code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950).
:
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..1ProblemObservationXML 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, moodCode, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1blThe negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.4
..... @extension 1..1stRequired Pattern: 2015-08-01
.... templateId:secondary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.114
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 1..*II
... code C1..1CDBinding: Problem Type (SNOMEDCT) (preferred)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: ASSERTION
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.4
.... @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
.... qualifier 0..*CR
.... translation 0..*CD
... 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_TSIf the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 1..1IVXB_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.