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: Health Concern Act (V2)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.132 Version: 2.2
Active as of 2022-05-13 Computable Name: HealthConcernAct
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.132:2015-08-01

This template represents a health concern.

It is a wrapper for a single health concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.).

A Health Concern Act is used to track non-optimal physical or psychological situations drawing the patient to the healthcare system. These may be from the perspective of the care team or from the perspective of the patient. When the underlying condition is of concern (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest), the statusCode is active. Only when the underlying condition is no longer of concern is the statusCode set to completed. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, a prior heart attack may remain a concern). Health concerns require intervention(s) to increase the likelihood of achieving the goals of care for the patient and they specify the condition oriented reasons for creating the plan.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Act

Summary

Mandatory: 11 elements (68 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • The element Act.entryRelationship is sliced based on the values of profile:observation, profile:act, profile:organizer

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... 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: 2.16.840.1.113883.10.20.22.4.132
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CD
.... code 1..1stringRequired Pattern: 75310-3
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CS
.... code 1..1stringBinding: ProblemAct statusCode (required)
... effectiveTime 0..1IVL_TS
... author 0..*AuthorParticipationA health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider.
... Slices for entryRelationship 0..*ElementWhere a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1ProblemObservation
.... entryRelationship:allergy-IntoleranceObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1AllergyIntoleranceObservation
.... entryRelationship:entryReference 0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: REFR
..... act I1..1EntryReference1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860).
.... entryRelationship:entryReference 0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: COMP
..... act I1..1EntryReference1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745).
.... entryRelationship:assessmentScaleObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1AssessmentScaleObservation
.... entryRelationship:self-CareActivities(ADLandIADL) 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SelfCareActivitiesADLandIADL
.... entryRelationship:mentalStatusObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1MentalStatusObservation
.... entryRelationship:smokingStatus-MeaningfulUse 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SmokingStatusMeaningfulUse
.... entryRelationship:encounterDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1EncounterDiagnosis
.... entryRelationship:entryRelationship10 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... organizer 1..1FamilyHistoryOrganizer
.... entryRelationship:functionalStatusObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1FunctionalStatusObservation
.... entryRelationship:hospitalAdmissionDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1HospitalAdmissionDiagnosis
.... entryRelationship:nutritionAssessment 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1NutritionAssessment
.... entryRelationship:postprocedureDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1PostprocedureDiagnosis
.... entryRelationship:pregnancyObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PregnancyObservation
.... entryRelationship:preoperativeDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1PreoperativeDiagnosis
.... entryRelationship:reactionObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1ReactionObservation
.... entryRelationship:resultObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1ResultObservation
.... entryRelationship:sensoryStatus 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SensoryStatus
.... entryRelationship:socialHistoryObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SocialHistoryObservation
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SubstanceOrDeviceAllergyIntoleranceObservation
.... entryRelationship:tobaccoUse 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1TobaccoUse
.... entryRelationship:vitalSignObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1VitalSignObservation
.... entryRelationship:longitudinalCareWoundObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1LongitudinalCareWoundObservation
.... entryRelationship:problemObservation 0..*ElementThe following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... typeCode 1..1codeRequired Pattern: SPRT
..... observation 1..1ProblemObservation
.... entryRelationship:caregiverCharacteristics 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:culturalandReligiousObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CulturalandReligiousObservation
.... entryRelationship:characteristicsofHomeEnvironment 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CharacteristicsofHomeEnvironment
.... entryRelationship:nutritionalStatusObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1NutritionalStatusObservation
.... entryRelationship:entryRelationship30 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... organizer 1..1ResultOrganizer
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that the patient or a provider puts on the health concern.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreference
.... entryRelationship:problemConcernAct 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1ProblemConcernAct
.... entryRelationship:entryReference 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1EntryReference
... reference 0..*ElementWhere it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
.... typeCode 1..1codeRequired Pattern: REFR
.... externalDocument 1..1ExternalDocumentReference

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... 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: 2.16.840.1.113883.10.20.22.4.132
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 1..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 75310-3
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... 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
.... qualifier 0..*CR
.... translation 0..*CD
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: ProblemAct 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 (extensible)
... languageCode 0..1CSBinding: HumanLanguage (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
... author 0..*AuthorParticipationA health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider.
... 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
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementWhere a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by profile:observation, profile:act, profile:organizer
.... 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:problemObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ProblemObservation
.... entryRelationship:allergy-IntoleranceObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AllergyIntoleranceObservation
.... entryRelationship:entryReference I0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act I1..1EntryReference1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860).
.... entryRelationship:entryReference I0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act I1..1EntryReference1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745).
.... entryRelationship:assessmentScaleObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleObservation
.... entryRelationship:self-CareActivities(ADLandIADL) I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SelfCareActivitiesADLandIADL
.... entryRelationship:mentalStatusObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1MentalStatusObservation
.... entryRelationship:smokingStatus-MeaningfulUse I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SmokingStatusMeaningfulUse
.... entryRelationship:encounterDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1EncounterDiagnosis
.... entryRelationship:entryRelationship10 I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... organizer 1..1FamilyHistoryOrganizer
.... entryRelationship:functionalStatusObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1FunctionalStatusObservation
.... entryRelationship:hospitalAdmissionDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1HospitalAdmissionDiagnosis
.... entryRelationship:nutritionAssessment I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1NutritionAssessment
.... entryRelationship:postprocedureDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PostprocedureDiagnosis
.... entryRelationship:pregnancyObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PregnancyObservation
.... entryRelationship:preoperativeDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PreoperativeDiagnosis
.... entryRelationship:reactionObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservation
.... entryRelationship:resultObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ResultObservation
.... entryRelationship:sensoryStatus I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SensoryStatus
.... entryRelationship:socialHistoryObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SocialHistoryObservation
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SubstanceOrDeviceAllergyIntoleranceObservation
.... entryRelationship:tobaccoUse I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1TobaccoUse
.... entryRelationship:vitalSignObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1VitalSignObservation
.... entryRelationship:longitudinalCareWoundObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1LongitudinalCareWoundObservation
.... entryRelationship:problemObservation I0..*ElementThe following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... typeCode 1..1codeRequired Pattern: SPRT
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ProblemObservation
.... entryRelationship:caregiverCharacteristics I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:culturalandReligiousObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CulturalandReligiousObservation
.... entryRelationship:characteristicsofHomeEnvironment I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CharacteristicsofHomeEnvironment
.... entryRelationship:nutritionalStatusObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1NutritionalStatusObservation
.... entryRelationship:entryRelationship30 I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... organizer 1..1ResultOrganizer
.... entryRelationship:priorityPreference I0..*ElementThe following entryRelationship represents the priority that the patient or a provider puts on the health concern.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreference
.... entryRelationship:problemConcernAct I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1ProblemConcernAct
.... entryRelationship:entryReference I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1EntryReference
... reference 0..*ElementWhere it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
.... typeCode 1..1codeRequired Pattern: REFR
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 1..1ExternalDocumentReference
... precondition 0..*Precondition

doco Documentation for this format

This structure is derived from CDAR2.Act

Summary

Mandatory: 11 elements (68 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • The element Act.entryRelationship is sliced based on the values of profile:observation, profile:act, profile:organizer

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... 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: 2.16.840.1.113883.10.20.22.4.132
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CD
.... code 1..1stringRequired Pattern: 75310-3
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CS
.... code 1..1stringBinding: ProblemAct statusCode (required)
... effectiveTime 0..1IVL_TS
... author 0..*AuthorParticipationA health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider.
... Slices for entryRelationship 0..*ElementWhere a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1ProblemObservation
.... entryRelationship:allergy-IntoleranceObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1AllergyIntoleranceObservation
.... entryRelationship:entryReference 0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: REFR
..... act I1..1EntryReference1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860).
.... entryRelationship:entryReference 0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: COMP
..... act I1..1EntryReference1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745).
.... entryRelationship:assessmentScaleObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1AssessmentScaleObservation
.... entryRelationship:self-CareActivities(ADLandIADL) 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SelfCareActivitiesADLandIADL
.... entryRelationship:mentalStatusObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1MentalStatusObservation
.... entryRelationship:smokingStatus-MeaningfulUse 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SmokingStatusMeaningfulUse
.... entryRelationship:encounterDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1EncounterDiagnosis
.... entryRelationship:entryRelationship10 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... organizer 1..1FamilyHistoryOrganizer
.... entryRelationship:functionalStatusObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1FunctionalStatusObservation
.... entryRelationship:hospitalAdmissionDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1HospitalAdmissionDiagnosis
.... entryRelationship:nutritionAssessment 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1NutritionAssessment
.... entryRelationship:postprocedureDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1PostprocedureDiagnosis
.... entryRelationship:pregnancyObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PregnancyObservation
.... entryRelationship:preoperativeDiagnosis 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1PreoperativeDiagnosis
.... entryRelationship:reactionObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1ReactionObservation
.... entryRelationship:resultObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1ResultObservation
.... entryRelationship:sensoryStatus 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SensoryStatus
.... entryRelationship:socialHistoryObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SocialHistoryObservation
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1SubstanceOrDeviceAllergyIntoleranceObservation
.... entryRelationship:tobaccoUse 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1TobaccoUse
.... entryRelationship:vitalSignObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1VitalSignObservation
.... entryRelationship:longitudinalCareWoundObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1LongitudinalCareWoundObservation
.... entryRelationship:problemObservation 0..*ElementThe following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... typeCode 1..1codeRequired Pattern: SPRT
..... observation 1..1ProblemObservation
.... entryRelationship:caregiverCharacteristics 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:culturalandReligiousObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CulturalandReligiousObservation
.... entryRelationship:characteristicsofHomeEnvironment 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CharacteristicsofHomeEnvironment
.... entryRelationship:nutritionalStatusObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1NutritionalStatusObservation
.... entryRelationship:entryRelationship30 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... organizer 1..1ResultOrganizer
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that the patient or a provider puts on the health concern.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreference
.... entryRelationship:problemConcernAct 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1ProblemConcernAct
.... entryRelationship:entryReference 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... act 1..1EntryReference
... reference 0..*ElementWhere it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
.... typeCode 1..1codeRequired Pattern: REFR
.... externalDocument 1..1ExternalDocumentReference

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... 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: 2.16.840.1.113883.10.20.22.4.132
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 1..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 75310-3
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... 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
.... qualifier 0..*CR
.... translation 0..*CD
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: ProblemAct 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 (extensible)
... languageCode 0..1CSBinding: HumanLanguage (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
... author 0..*AuthorParticipationA health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider.
... 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
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementWhere a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by profile:observation, profile:act, profile:organizer
.... 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:problemObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ProblemObservation
.... entryRelationship:allergy-IntoleranceObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AllergyIntoleranceObservation
.... entryRelationship:entryReference I0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act I1..1EntryReference1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860).
.... entryRelationship:entryReference I0..*ElementThe following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act I1..1EntryReference1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745).
.... entryRelationship:assessmentScaleObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleObservation
.... entryRelationship:self-CareActivities(ADLandIADL) I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SelfCareActivitiesADLandIADL
.... entryRelationship:mentalStatusObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1MentalStatusObservation
.... entryRelationship:smokingStatus-MeaningfulUse I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SmokingStatusMeaningfulUse
.... entryRelationship:encounterDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1EncounterDiagnosis
.... entryRelationship:entryRelationship10 I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... organizer 1..1FamilyHistoryOrganizer
.... entryRelationship:functionalStatusObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1FunctionalStatusObservation
.... entryRelationship:hospitalAdmissionDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1HospitalAdmissionDiagnosis
.... entryRelationship:nutritionAssessment I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1NutritionAssessment
.... entryRelationship:postprocedureDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PostprocedureDiagnosis
.... entryRelationship:pregnancyObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PregnancyObservation
.... entryRelationship:preoperativeDiagnosis I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PreoperativeDiagnosis
.... entryRelationship:reactionObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservation
.... entryRelationship:resultObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ResultObservation
.... entryRelationship:sensoryStatus I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SensoryStatus
.... entryRelationship:socialHistoryObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SocialHistoryObservation
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SubstanceOrDeviceAllergyIntoleranceObservation
.... entryRelationship:tobaccoUse I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1TobaccoUse
.... entryRelationship:vitalSignObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1VitalSignObservation
.... entryRelationship:longitudinalCareWoundObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1LongitudinalCareWoundObservation
.... entryRelationship:problemObservation I0..*ElementThe following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... typeCode 1..1codeRequired Pattern: SPRT
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ProblemObservation
.... entryRelationship:caregiverCharacteristics I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:culturalandReligiousObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CulturalandReligiousObservation
.... entryRelationship:characteristicsofHomeEnvironment I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CharacteristicsofHomeEnvironment
.... entryRelationship:nutritionalStatusObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1NutritionalStatusObservation
.... entryRelationship:entryRelationship30 I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... organizer 1..1ResultOrganizer
.... entryRelationship:priorityPreference I0..*ElementThe following entryRelationship represents the priority that the patient or a provider puts on the health concern.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreference
.... entryRelationship:problemConcernAct I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1ProblemConcernAct
.... entryRelationship:entryReference I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1EntryReference
... reference 0..*ElementWhere it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
.... typeCode 1..1codeRequired Pattern: REFR
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 1..1ExternalDocumentReference
... precondition 0..*Precondition

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.statusCoderequiredActStatus
Act.statusCode.nullFlavorrequiredNullFlavor
Act.statusCode.coderequiredProblemAct statusCode
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
act-er-1errorAct.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:problemObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:allergy-IntoleranceObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:entryReferenceOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:entryReferenceOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:assessmentScaleObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:self-CareActivities(ADLandIADL)Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:mentalStatusObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:smokingStatus-MeaningfulUseOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:encounterDiagnosisOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:entryRelationship10Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:functionalStatusObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:hospitalAdmissionDiagnosisOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:nutritionAssessmentOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:postprocedureDiagnosisOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:pregnancyObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:preoperativeDiagnosisOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:reactionObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:resultObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:sensoryStatusOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:socialHistoryObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:substanceorDeviceAllergy-IntoleranceObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:tobaccoUseOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:vitalSignObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:longitudinalCareWoundObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:problemObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:caregiverCharacteristicsOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:culturalandReligiousObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:characteristicsofHomeEnvironmentOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:nutritionalStatusObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:entryRelationship30Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:priorityPreferenceOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:problemConcernActOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:entryReferenceOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1