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: Planned Observation

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.44 Version: 2.2
Active as of 2022-05-13 Computable Name: PlannedObservation
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09

This template represents planned observations that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM, i.e., procedures alter the patient’s body. Examples of these observations are laboratory tests, diagnostic imaging tests, EEGs, and EKGs.

The importance of the planned observation to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the observation is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Observation template may also indicate the potential insurance coverage for the observation.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Observation

Summary

Mandatory: 9 elements (8 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... value 0..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
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... Slices for entryRelationship 0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreference
.... entryRelationship:indication 0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:instruction 0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... act 1..1Instruction
.... entryRelationship:plannedCoverage 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1PlannedCoverage

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... 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: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: active
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..1
.... 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 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
Binding: ObservationMethod (extensible)
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: 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..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... 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..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... 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:priorityPreference I0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreference
.... entryRelationship:indication I0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:instruction I0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:plannedCoverage I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PlannedCoverage
... 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

Summary

Mandatory: 9 elements (8 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... value 0..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
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... Slices for entryRelationship 0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreference
.... entryRelationship:indication 0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:instruction 0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... act 1..1Instruction
.... entryRelationship:plannedCoverage 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1PlannedCoverage

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... 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: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: active
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..1
.... 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 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
Binding: ObservationMethod (extensible)
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: 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..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... 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..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... 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:priorityPreference I0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreference
.... entryRelationship:indication I0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:instruction I0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:plannedCoverage I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PlannedCoverage
... 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.moodCoderequiredPlanned moodCode (Observation)
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCoderequiredBodySiteValueSet
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePathDetailsRequirements
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:priorityPreferenceOnly 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: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:plannedCoverageOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1