Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Procedure Activity Observation

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.13 Version: 2.2
Active as of 2022-05-13 Computable Name: ProcedureActivityObservation
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09

The common notion of procedure is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy).

This template represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs, and EKGs.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Observation

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.13
..... extension 1..1stringRequired Pattern: 2014-06-09
... code I1..1CD1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202).
.... originalText 0..1ED
..... reference 0..1TEL
...... value I0..1uri1098-19201: 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:1098-19201).
... statusCode 1..1CS
.... code 1..1stringBinding: ProcedureAct statusCode (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... value 1..1BL, ED, ED, 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
​.... nullFlavor 0..1If nothing is appropriate for value, use an appropriate nullFlavor.
... methodCode I0..1CE1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... performer 0..*Performer2
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... addr 1..*AD
..... telecom 1..*TEL
..... representedOrganization 0..1Organization
...... id 0..*II
...... name 0..*ON
...... telecom 1..1TEL
...... addr 1..1AD
... author 0..*AuthorParticipation
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode, value:participantRole
.... participant:location 0..*Participant2
..... typeCode 1..1codeRequired Pattern: LOC
..... participantRole 1..1ServiceDeliveryLocation
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration
.... entryRelationship:encounter 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... encounter 1..1Encounter
​...... classCode 1..1codeRequired Pattern: ENC
​...... moodCode 1..1codeRequired Pattern: EVN
​...... id I1..1II1098-16847: Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847).
.... entryRelationship:instruction 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... act 1..1Instruction
.... entryRelationship:indication 0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:medication 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... substanceAdministration 1..1MedicationActivity
.... entryRelationship:reaction 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1ReactionObservation

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.13
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code I1..1CDBinding: ObservationType (extensible)
1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202).
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... charset 0..1code
..... compression 0..1codeBinding: CompressionAlgorithm (required)
..... integrityCheck 0..1base64Binary
..... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
..... language 0..1code
..... mediaType 0..1code
..... representation 0..1code
..... data[x] 0..1
...... dataStringstring
...... dataBase64Binarybase64Binary
..... reference 0..1TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value I0..1uri1098-19201: 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:1098-19201).
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..*codeBinding: AddressUse (required)
..... thumbnail 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: ProcedureAct statusCode (required)
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1
.... value:All Types Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... valueBL
.... valueED
.... valueED
.... 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)
... methodCode I0..1CEBinding: ObservationMethod (extensible)
1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
.... time 0..1IVL_TS
.... modeCode 0..1CE
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: v3 Code System RoleCode (extensible)
..... addr 1..*AD
..... telecom 1..*TEL
..... assignedPerson 0..1Person
..... representedOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..*II
...... name 0..*ON
...... telecom 1..1TEL
...... addr 1..1AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 0..*AuthorParticipation
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode, value:participantRole
.... participant:location 0..*Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: LOC
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ServiceDeliveryLocation
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:encounter I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... encounter 1..1Encounter
.... entryRelationship:instruction I0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:indication I0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:medication I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... substanceAdministration I1..1MedicationActivity
.... entryRelationship:reaction I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservation
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

This structure is derived from CDAR2.Observation

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.13
..... extension 1..1stringRequired Pattern: 2014-06-09
... code I1..1CD1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202).
.... originalText 0..1ED
..... reference 0..1TEL
...... value I0..1uri1098-19201: 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:1098-19201).
... statusCode 1..1CS
.... code 1..1stringBinding: ProcedureAct statusCode (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... value 1..1BL, ED, ED, 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
​.... nullFlavor 0..1If nothing is appropriate for value, use an appropriate nullFlavor.
... methodCode I0..1CE1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... performer 0..*Performer2
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... addr 1..*AD
..... telecom 1..*TEL
..... representedOrganization 0..1Organization
...... id 0..*II
...... name 0..*ON
...... telecom 1..1TEL
...... addr 1..1AD
... author 0..*AuthorParticipation
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode, value:participantRole
.... participant:location 0..*Participant2
..... typeCode 1..1codeRequired Pattern: LOC
..... participantRole 1..1ServiceDeliveryLocation
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration
.... entryRelationship:encounter 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... encounter 1..1Encounter
​...... classCode 1..1codeRequired Pattern: ENC
​...... moodCode 1..1codeRequired Pattern: EVN
​...... id I1..1II1098-16847: Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847).
.... entryRelationship:instruction 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... act 1..1Instruction
.... entryRelationship:indication 0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:medication 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... substanceAdministration 1..1MedicationActivity
.... entryRelationship:reaction 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1ReactionObservation

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.13
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code I1..1CDBinding: ObservationType (extensible)
1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202).
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... charset 0..1code
..... compression 0..1codeBinding: CompressionAlgorithm (required)
..... integrityCheck 0..1base64Binary
..... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
..... language 0..1code
..... mediaType 0..1code
..... representation 0..1code
..... data[x] 0..1
...... dataStringstring
...... dataBase64Binarybase64Binary
..... reference 0..1TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value I0..1uri1098-19201: 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:1098-19201).
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..*codeBinding: AddressUse (required)
..... thumbnail 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: ProcedureAct statusCode (required)
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1
.... value:All Types Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... valueBL
.... valueED
.... valueED
.... 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)
... methodCode I0..1CEBinding: ObservationMethod (extensible)
1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
.... time 0..1IVL_TS
.... modeCode 0..1CE
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: v3 Code System RoleCode (extensible)
..... addr 1..*AD
..... telecom 1..*TEL
..... assignedPerson 0..1Person
..... representedOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..*II
...... name 0..*ON
...... telecom 1..1TEL
...... addr 1..1AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 0..*AuthorParticipation
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode, value:participantRole
.... participant:location 0..*Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: LOC
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ServiceDeliveryLocation
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:encounter I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... encounter 1..1Encounter
.... entryRelationship:instruction I0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:indication I0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:medication I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... substanceAdministration I1..1MedicationActivity
.... entryRelationship:reaction I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservation
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.code.originalText.nullFlavorrequiredNullFlavor
Observation.code.originalText.compressionrequiredCompressionAlgorithm
Observation.code.originalText.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.code.originalText.reference.nullFlavorrequiredNullFlavor
Observation.code.originalText.reference.userequiredAddressUse
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.statusCode.coderequiredProcedureAct statusCode
Observation.priorityCoderequiredActPriority
Observation.languageCoderequiredHumanLanguage
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCoderequiredBodySiteValueSet
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.performer.nullFlavorrequiredNullFlavor
Observation.performer.typeCoderequiredFixed Value: PRF
Observation.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
Observation.performer.assignedEntity.codeextensibleRoleCode
Observation.performer.assignedEntity.representedOrganization.classCoderequiredFixed Value: ORG
Observation.performer.assignedEntity.representedOrganization.determinerCoderequiredFixed Value: INSTANCE
Observation.performer.assignedEntity.representedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.participant:location.nullFlavorrequiredNullFlavor
Observation.participant:location.typeCoderequiredPattern: LOC
Observation.participant:location.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePathDetailsRequirements
1098-19202warningObservation.codeThis @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202).
:
1098-19201errorObservation.code.originalText.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:1098-19201).
:
ele-1errorObservation.value.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorObservation.value.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
1098-8249errorObservation.methodCodeMethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249).
:
obs-er-1errorObservation.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:encounterOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:instructionOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:indicationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:medicationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
1098-30800warningObservation.entryRelationship:medication.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
obs-er-1errorObservation.entryRelationship:reactionOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1