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: FunctionalStatusProblemObservation - Detailed Descriptions

Draft as of 2022-05-13

Definitions for the 2.16.840.1.113883.10.20.22.4.68 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" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-14282).

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:1098-14283).

Pattern ValueEVN
4. Observation.negationInd
Control0..1
Typeboolean
Requirements

MAY contain zero or one [0..1] @negationInd (CONF:1098-14307).

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 @ root
  • ,
  • value @ extension
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:1098-14312) 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="2.16.840.1.113883.10.20.22.4.68" (CONF:1098-14313).

Pattern Value2.16.840.1.113883.10.20.22.4.68
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="2014-06-09" (CONF:1098-32601).

Pattern Value2014-06-09
14. Observation.id
Control1..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain at least one [1..*] id (CONF:1098-14284).

15. Observation.code
Control1..1
BindingThe codes SHALL be taken from ObservationType; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

SHALL contain exactly one [1..1] code (CONF:1098-14314).

16. Observation.code.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
17. Observation.code.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.

Control0..1
Typestring
Requirements

This code SHOULD contain zero or one [0..1] @code="248536006" finding of functional performance and activity (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96 STATIC) (CONF:1098-14315).

Pattern Value248536006
18. Observation.code.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring
19. Observation.code.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring
20. Observation.code.codeSystemVersion
Definition

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

Control0..1
Typestring
21. Observation.code.displayName
Definition

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

Control0..1
Typestring
22. Observation.code.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
23. Observation.code.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
24. Observation.code.originalText
Definition

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

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
25. Observation.code.qualifier
Definition

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

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
26. Observation.code.translation
Definition

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

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
27. Observation.derivationExpr
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ST
28. Observation.text
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
Requirements

SHOULD contain zero or one [0..1] text (CONF:1098-14304).

29. Observation.text.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
30. Observation.text.charset
Definition

For character-based encoding types, this property specifies the character set and character encoding used. The charset shall be identified by an Internet Assigned Numbers Authority (IANA) Charset Registration [] in accordance with RFC 2978 [].

Control0..1
Typecode
31. Observation.text.compression
Definition

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

Control0..1
BindingThe codes SHALL be taken from CompressionAlgorithm
Typecode
32. Observation.text.integrityCheck
Definition

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Control0..1
Typebase64Binary
33. Observation.text.integrityCheckAlgorithm
Definition

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

Control0..1
BindingThe codes SHALL be taken from IntegrityCheckAlgorithm
Typecode
34. Observation.text.language
Definition

For character based information the language property specifies the human language of the text.

Control0..1
Typecode
35. Observation.text.mediaType
Definition

Identifies the type of the encapsulated data and identifies a method to interpret or render the data.

Control0..1
Typecode
36. Observation.text.representation
Control0..1
Typecode
37. Observation.text.data[x]
Definition

Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)

Control0..1
TypeChoice of: string, base64Binary
[x] NoteSee Choice of Data Types for further information about how to use [x]
38. Observation.text.reference
Definition

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/TEL
Requirements

The text, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-15552).

39. Observation.text.reference.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
40. Observation.text.reference.value
Control0..1
Typeuri
Requirements

The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-15553).

InvariantsDefined on this element
1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554). (: )
41. Observation.text.reference.useablePeriod
Definition

Specifies the periods of time during which the telecommunication address can be used. For a telephone number, this can indicate the time of day in which the party can be reached on that telephone. For a web address, it may specify a time range in which the web content is promised to be available under the given address.

Control0..*
TypeChoice of: http://hl7.org/fhir/cda/StructureDefinition/IVL-TS, http://hl7.org/fhir/cda/StructureDefinition/EIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/PIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/SXPR-TS
42. Observation.text.reference.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Control0..*
BindingThe codes SHALL be taken from AddressUse
Typecode
43. Observation.text.thumbnail
Definition

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
44. 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:1098-14286).

45. 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
46. 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:1098-19100).

Pattern Valuecompleted
47. Observation.statusCode.codeSystem
Definition

Specifies the code system that defines the code.

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

The common name of the coding system.

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

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

Control0..0
Typestring
50. 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
51. 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
52. 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
53. Observation.statusCode.originalText
Definition

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

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
54. 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
55. 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
56. Observation.effectiveTime
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS
Requirements

SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-14287).

57. Observation.effectiveTime.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
58. Observation.effectiveTime.value
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

Control0..1
TypedateTime
59. Observation.effectiveTime.inclusive
Definition

Specifies whether the limit is included in the interval (interval is closed) or excluded from the interval (interval is open).

Control0..1
Typeboolean
60. Observation.effectiveTime.operator
Definition

A code specifying whether the set component is included (union) or excluded (set-difference) from the set, or other set operations with the current set component and the set as constructed from the representation stream up to the current point.

Control0..1
Typecode
61. Observation.effectiveTime.low
Definition

This is the low limit of the interval.

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

The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:1098-26456).

62. Observation.effectiveTime.high
Definition

This is the high limit of the interval.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/TS
Requirements

The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:1098-26457).

63. Observation.effectiveTime.width
Definition

The difference between high and low boundary. The purpose of distinguishing a width property is to handle all cases of incomplete information symmetrically. In any interval representation only two of the three properties high, low, and width need to be stated and the third can be derived.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/PQ
64. Observation.effectiveTime.center
Definition

The arithmetic mean of the interval (low plus high divided by 2). The purpose of distinguishing the center as a semantic property is for conversions of intervals from and to point values.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/TS
65. 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
66. Observation.repeatNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-INT
67. Observation.languageCode
Control0..1
BindingThe codes SHALL be taken from HumanLanguage
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
68. Observation.value
Control1..1
BindingThe codes SHOULD be taken from Problem
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:1098-14291).

69. Observation.value.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
Requirements

This value MAY contain zero or one [0..1] @nullFlavor (CONF:1098-14292).

InvariantsDefined on this element
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293). (: )
70. Observation.value.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.

Control0..1
Typestring
71. Observation.value.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring
72. Observation.value.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring
73. Observation.value.codeSystemVersion
Definition

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

Control0..1
Typestring
74. Observation.value.displayName
Definition

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

Control0..1
Typestring
75. Observation.value.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
76. Observation.value.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
77. Observation.value.originalText
Definition

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

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
78. Observation.value.qualifier
Definition

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

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
79. Observation.value.translation
Definition

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

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
80. Observation.interpretationCode
Control0..*
BindingThe codes SHALL be taken from ObservationInterpretation
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
81. Observation.methodCode
Control0..1
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
Requirements

MAY contain zero or one [0..1] methodCode (CONF:1098-14316).

82. Observation.targetSiteCode
Definition

Drawn from concept domain ActSite

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
83. Observation.subject
Control0..1
TypeElement
84. Observation.subject.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetSubject
Typecode
Default ValueSBJ
Fixed ValueSBJ
85. Observation.subject.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
86. 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
87. Observation.subject.relatedSubject
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
88. Observation.specimen
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Specimen
89. Observation.performer
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Performer2
90. Observation.author
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Author
91. Observation.informant
Control0..*
TypeElement
92. Observation.informant.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationInformationGenerator
Typecode
Default ValueINF
Fixed ValueINF
93. Observation.informant.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
94. Observation.informant.assignedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
95. Observation.informant.relatedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
96. Observation.participant
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Participant2
97. 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)
98. Observation.entryRelationship.typeCode
Control1..1
Typecode
99. Observation.entryRelationship.inversionInd
Control0..1
Typeboolean
100. Observation.entryRelationship.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
101. Observation.entryRelationship.sequenceNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/INT
102. Observation.entryRelationship.negationInd
Control0..1
Typeboolean
103. Observation.entryRelationship.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
104. Observation.entryRelationship.observation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
105. Observation.entryRelationship.regionOfInterest
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
106. Observation.entryRelationship.observationMedia
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
107. Observation.entryRelationship.substanceAdministration
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
108. Observation.entryRelationship.supply
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
109. Observation.entryRelationship.procedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
110. Observation.entryRelationship.encounter
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
111. Observation.entryRelationship.organizer
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
112. Observation.entryRelationship.act
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
113. Observation.reference
Control0..*
TypeElement
114. Observation.reference.typeCode
Control1..1
Typecode
115. Observation.reference.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
116. Observation.reference.externalAct
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalAct
117. Observation.reference.externalObservation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalObservation
118. Observation.reference.externalProcedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure
119. Observation.reference.externalDocument
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalDocument
120. Observation.precondition
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Precondition
121. Observation.referenceRange
Control0..*
TypeElement
122. Observation.referenceRange.typeCode
Control1..1
BindingThe codes SHALL be taken from ActRelationshipPertains
Typecode
Default ValueREFV
Fixed ValueREFV
123. Observation.referenceRange.observationRange
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationRange