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: SocialHistoryObservation - Detailed Descriptions

Active as of 2022-05-13

Definitions for the 2.16.840.1.113883.10.20.22.4.38 resource profile.

1. Observation
Control1..1
2. Observation.classCode
Control1..1
BindingThe codes SHALL be taken from ActClassObservation
Typecode
Requirements

SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-8548).

Pattern ValueOBS
3. Observation.moodCode
Control1..1
Typecode
Requirements

SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-8549).

Pattern ValueEVN
4. Observation.negationInd
Control0..1
Typeboolean
5. Observation.realmCode
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
6. Observation.typeId
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
7. Observation.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
SlicingThis element introduces a set of slices on Observation.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ extension
  • ,
  • value @ root
8. Observation.templateId:primary
SliceNameprimary
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain exactly one [1..1] templateId (CONF:1198-8550) such that it

9. Observation.templateId:primary.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
10. Observation.templateId:primary.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring
11. Observation.templateId:primary.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean
12. Observation.templateId:primary.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.38" (CONF:1198-10526).

Pattern Value2.16.840.1.113883.10.20.22.4.38
13. Observation.templateId:primary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32495).

Pattern Value2015-08-01
14. Observation.id
Control1..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain at least one [1..*] id (CONF:1198-8551).

15. Observation.code
Control1..1
BindingThe codes SHOULD be taken from Social History Type
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Social History Type urn:oid:2.16.840.1.113883.3.88.12.80.60 DYNAMIC (CONF:1198-8558).

InvariantsDefined on this element
1198-32951: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32951). (: )
16. Observation.derivationExpr
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ST
17. Observation.text
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
18. Observation.statusCode
Control1..1
BindingThe codes SHALL be taken from ActStatus
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
Requirements

SHALL contain exactly one [1..1] statusCode (CONF:1198-8553).

19. Observation.statusCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
20. Observation.statusCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typestring
Requirements

This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:1198-19117).

Pattern Valuecompleted
21. Observation.statusCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring
22. Observation.statusCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring
23. Observation.statusCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring
24. Observation.statusCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring
25. Observation.statusCode.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring
26. Observation.statusCode.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring
27. Observation.statusCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
28. Observation.statusCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
29. Observation.statusCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
30. Observation.effectiveTime
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS
Requirements

SHALL contain exactly one [1..1] effectiveTime (CONF:1198-31868).

31. Observation.priorityCode
Control0..1
BindingThe codes SHALL be taken from ActPriority; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
32. Observation.repeatNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-INT
33. Observation.languageCode
Control0..1
BindingThe codes SHALL be taken from HumanLanguage
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
34. Observation.value
Control0..1
TypeChoice of: http://hl7.org/fhir/cda/StructureDefinition/BL, http://hl7.org/fhir/cda/StructureDefinition/ED, http://hl7.org/fhir/cda/StructureDefinition/ST, http://hl7.org/fhir/cda/StructureDefinition/CD, http://hl7.org/fhir/cda/StructureDefinition/CV, http://hl7.org/fhir/cda/StructureDefinition/CE, http://hl7.org/fhir/cda/StructureDefinition/SC, http://hl7.org/fhir/cda/StructureDefinition/II, http://hl7.org/fhir/cda/StructureDefinition/TEL, http://hl7.org/fhir/cda/StructureDefinition/AD, http://hl7.org/fhir/cda/StructureDefinition/EN, http://hl7.org/fhir/cda/StructureDefinition/INT, http://hl7.org/fhir/cda/StructureDefinition/REAL, http://hl7.org/fhir/cda/StructureDefinition/PQ, http://hl7.org/fhir/cda/StructureDefinition/MO, http://hl7.org/fhir/cda/StructureDefinition/TS, http://hl7.org/fhir/cda/StructureDefinition/IVL-PQ, http://hl7.org/fhir/cda/StructureDefinition/IVL-TS, http://hl7.org/fhir/cda/StructureDefinition/PIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/EIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/SXPR-TS, http://hl7.org/fhir/cda/StructureDefinition/RTO-PQ-PQ
Requirements

SHOULD contain zero or one [0..1] value (CONF:1198-8559).

InvariantsDefined on this element
1198-8555: If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive (2.16.840.1.113883.1.11.12839) *DYNAMIC* (CONF:1198-8555). (: )
35. Observation.interpretationCode
Control0..*
BindingThe codes SHALL be taken from ObservationInterpretation
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
36. Observation.methodCode
Control0..*
BindingThe codes SHALL be taken from ObservationMethod; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
37. Observation.targetSiteCode
Definition

Drawn from concept domain ActSite

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
38. Observation.subject
Control0..1
TypeElement
39. Observation.subject.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetSubject
Typecode
Default ValueSBJ
Fixed ValueSBJ
40. Observation.subject.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
41. Observation.subject.awarenessCode
Control0..1
BindingThe codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
42. Observation.subject.relatedSubject
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
43. Observation.specimen
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Specimen
44. Observation.performer
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Performer2
45. Observation.author
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Author(AuthorParticipation)
Requirements

SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31869).

46. Observation.informant
Control0..*
TypeElement
47. Observation.informant.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationInformationGenerator
Typecode
Default ValueINF
Fixed ValueINF
48. Observation.informant.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
49. Observation.informant.assignedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
50. Observation.informant.relatedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
51. Observation.participant
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Participant2
52. Observation.entryRelationship
Control0..*
TypeElement
InvariantsDefined on this element
obs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act (: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1)
53. Observation.entryRelationship.typeCode
Control1..1
Typecode
54. Observation.entryRelationship.inversionInd
Control0..1
Typeboolean
55. Observation.entryRelationship.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
56. Observation.entryRelationship.sequenceNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/INT
57. Observation.entryRelationship.negationInd
Control0..1
Typeboolean
58. Observation.entryRelationship.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
59. Observation.entryRelationship.observation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
60. Observation.entryRelationship.regionOfInterest
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
61. Observation.entryRelationship.observationMedia
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
62. Observation.entryRelationship.substanceAdministration
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
63. Observation.entryRelationship.supply
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
64. Observation.entryRelationship.procedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
65. Observation.entryRelationship.encounter
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
66. Observation.entryRelationship.organizer
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
67. Observation.entryRelationship.act
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
68. Observation.reference
Control0..*
TypeElement
69. Observation.reference.typeCode
Control1..1
Typecode
70. Observation.reference.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
71. Observation.reference.externalAct
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalAct
72. Observation.reference.externalObservation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalObservation
73. Observation.reference.externalProcedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure
74. Observation.reference.externalDocument
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalDocument
75. Observation.precondition
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Precondition
76. Observation.referenceRange
Control0..*
TypeElement
77. Observation.referenceRange.typeCode
Control1..1
BindingThe codes SHALL be taken from ActRelationshipPertains
Typecode
Default ValueREFV
Fixed ValueREFV
78. Observation.referenceRange.observationRange
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationRange