Specialty Eyecare CDA Implementation Guide
0.1.0 - ci-build

Specialty Eyecare CDA Implementation Guide, published by Dogwood Health Consulting. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cda-eyecare/ and changes regularly. See the Directory of published versions

Logical Model: VisualAcuityTestUnitObservation

Official URL: http://hl7.org/cda/us/eyecare/StructureDefinition/VisualAcuityTestUnitObservation Version: 0.1.0
Draft as of 2024-02-07 Computable Name: VisualAcuityTestUnitObservation

An observation that conveys the units of the Visual Acuity test since we can not use a PQ since the acuity result is not a number.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C1..1ResultObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:result-obs 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.2
..... @extension 1..1stRequired Pattern: 2023-05-01
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
Fixed Value: OBS
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... code C1..1CD(USCDI) Tests
Binding: ObservationType (example)
.... @code 0..1csRequired Pattern: 246514001
.... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
.... @displayName 0..1stRequired Pattern: units
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csBinding: Result Status (required)
... effectiveTime 1..1IVL_TSRepresents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
... Slices for value 1..1(USCDI) Values/Results - Value can be any type, but certain types have additional rules.
Slice: Unordered, Open by type:$this
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
.... value:coded C1..1CD
..... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.8
..... translation 0..1CDCan be used to represent the original results as output by the lab
... methodCode 0..1CEBinding: ObservationMethod (example)
... targetSiteCode 0..1CD

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.classCoderequiredFixed Value: OBS
http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.coderequiredResult Status
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod

Constraints

IdGradePath(s)DetailsRequirements
4537-19212warningObservation.codeThis code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32610warningObservation.value:codedIf Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610).
: codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1'
shall-code-or-nullflavorerrorObservation.codeSHALL contain either a @code attribute or a @nullFlavor attribute, but not both.
: (code | nullFlavor).count() = 1
should-authorwarningObservationSHOULD contain author
: author.exists()
should-interpretationCodewarningObservationSHOULD contain interpretationCode
: interpretationCode.exists()
should-referenceRangewarningObservationSHOULD contain referenceRange
: referenceRange.exists()
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C1..1ResultObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:result-obs 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.2
..... @extension 1..1stRequired Pattern: 2023-05-01
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
Fixed Value: OBS
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1bl
... id 1..*II
... code C1..1CD(USCDI) Tests
Binding: ObservationType (example)
.... (Choice of one) 1..1
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 0..1csRequired Pattern: 246514001
.... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1stRequired Pattern: units
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ST
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TEL
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csBinding: Result Status (required)
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TSRepresents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... Slices for value 1..1(USCDI) Values/Results - Value can be any type, but certain types have additional rules.
Slice: Unordered, Open by type:$this
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
.... value:coded C1..1CD
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 0..1cs
..... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.8
..... @codeSystemName 0..1st
..... @codeSystemVersion 0..1st
..... @displayName 0..1st
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
..... originalText 0..1ED
..... qualifier 0..*CR
..... translation 0..1CDCan be used to represent the original results as output by the lab
... interpretationCode 0..*CE(USCDI) Result Interpretation
Binding: ObservationInterpretation (required)
... methodCode 0..1CEBinding: ObservationMethod (example)
... targetSiteCode 0..1CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot(USCDI) Result Reference Range
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipType (2.0.0) (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClassObservation (required)
..... @moodCode 0..1csBinding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... text 0..1ED
..... value 1..1
...... valueBL
...... valueED
...... valueST
...... valueCD
...... valueCV
...... valueCE
...... valueCO
...... valueSC
...... valueII
...... valueTEL
...... valueAD
...... valueEN
...... valueINT
...... valueREAL
...... valuePQ
...... valueMO
...... valueTS
...... valueIVL_PQ
...... valueIVL_TS
...... valuePIVL_TS
...... valueEIVL_TS
...... valueSXPR_TS
..... interpretationCode 0..1CEBinding: ObservationInterpretation (required)
..... sdtcPrecondition1 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: precondition1 (urn:hl7-org:sdtc)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ActRelationshipType (required)
Fixed Value: PRCN
...... conjunctionCode 1..1CSXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
Binding: RelationshipConjunction (2.0.0) (required)
...... criterion1 1..1CriterionXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:result-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCoderequiredFixed Value: OBS
http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.statusCode.coderequiredResult Status
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39
Observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Observation.value:physical-quantity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.value:coded.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.interpretationCoderequiredObservationInterpretation
http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV
http://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0
Observation.referenceRange.observationRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.classCoderequiredActClassObservation
http://terminology.hl7.org/ValueSet/v3-ActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Observation.referenceRange.observationRange.interpretationCoderequiredObservationInterpretation
http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCoderequiredFixed Value: PRCN
http://terminology.hl7.org/ValueSet/v3-ActRelationshipType
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCoderequiredRelationshipConjunction
http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0

Constraints

IdGradePath(s)DetailsRequirements
4537-19212warningObservation.codeThis code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32610warningObservation.value:codedIf Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610).
: codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1'
shall-code-or-nullflavorerrorObservation.codeSHALL contain either a @code attribute or a @nullFlavor attribute, but not both.
: (code | nullFlavor).count() = 1
should-authorwarningObservationSHOULD contain author
: author.exists()
should-interpretationCodewarningObservationSHOULD contain interpretationCode
: interpretationCode.exists()
should-referenceRangewarningObservationSHOULD contain referenceRange
: referenceRange.exists()
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from ResultObservation

Summary

Mandatory: 1 element
Prohibited: 1 element

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C1..1ResultObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:result-obs 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.2
..... @extension 1..1stRequired Pattern: 2023-05-01
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
Fixed Value: OBS
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... code C1..1CD(USCDI) Tests
Binding: ObservationType (example)
.... @code 0..1csRequired Pattern: 246514001
.... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
.... @displayName 0..1stRequired Pattern: units
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csBinding: Result Status (required)
... effectiveTime 1..1IVL_TSRepresents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
... Slices for value 1..1(USCDI) Values/Results - Value can be any type, but certain types have additional rules.
Slice: Unordered, Open by type:$this
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
.... value:coded C1..1CD
..... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.8
..... translation 0..1CDCan be used to represent the original results as output by the lab
... methodCode 0..1CEBinding: ObservationMethod (example)
... targetSiteCode 0..1CD

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.classCoderequiredFixed Value: OBS
http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.coderequiredResult Status
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod

Constraints

IdGradePath(s)DetailsRequirements
4537-19212warningObservation.codeThis code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32610warningObservation.value:codedIf Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610).
: codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1'
shall-code-or-nullflavorerrorObservation.codeSHALL contain either a @code attribute or a @nullFlavor attribute, but not both.
: (code | nullFlavor).count() = 1
should-authorwarningObservationSHOULD contain author
: author.exists()
should-interpretationCodewarningObservationSHOULD contain interpretationCode
: interpretationCode.exists()
should-referenceRangewarningObservationSHOULD contain referenceRange
: referenceRange.exists()
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C1..1ResultObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:result-obs 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.2
..... @extension 1..1stRequired Pattern: 2023-05-01
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
Fixed Value: OBS
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1bl
... id 1..*II
... code C1..1CD(USCDI) Tests
Binding: ObservationType (example)
.... (Choice of one) 1..1
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 0..1csRequired Pattern: 246514001
.... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1stRequired Pattern: units
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ST
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TEL
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csBinding: Result Status (required)
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TSRepresents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... Slices for value 1..1(USCDI) Values/Results - Value can be any type, but certain types have additional rules.
Slice: Unordered, Open by type:$this
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
.... value:coded C1..1CD
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @code 0..1cs
..... @codeSystem 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.8
..... @codeSystemName 0..1st
..... @codeSystemVersion 0..1st
..... @displayName 0..1st
..... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
..... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
..... originalText 0..1ED
..... qualifier 0..*CR
..... translation 0..1CDCan be used to represent the original results as output by the lab
... interpretationCode 0..*CE(USCDI) Result Interpretation
Binding: ObservationInterpretation (required)
... methodCode 0..1CEBinding: ObservationMethod (example)
... targetSiteCode 0..1CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot(USCDI) Result Reference Range
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipType (2.0.0) (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 1..1csBinding: ActClassObservation (required)
..... @moodCode 0..1csBinding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... text 0..1ED
..... value 1..1
...... valueBL
...... valueED
...... valueST
...... valueCD
...... valueCV
...... valueCE
...... valueCO
...... valueSC
...... valueII
...... valueTEL
...... valueAD
...... valueEN
...... valueINT
...... valueREAL
...... valuePQ
...... valueMO
...... valueTS
...... valueIVL_PQ
...... valueIVL_TS
...... valuePIVL_TS
...... valueEIVL_TS
...... valueSXPR_TS
..... interpretationCode 0..1CEBinding: ObservationInterpretation (required)
..... sdtcPrecondition1 0..*InfrastructureRootXML Namespace: urn:hl7-org:sdtc
XML: precondition1 (urn:hl7-org:sdtc)
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csBinding: ActRelationshipType (required)
Fixed Value: PRCN
...... conjunctionCode 1..1CSXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
Binding: RelationshipConjunction (2.0.0) (required)
...... criterion1 1..1CriterionXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:result-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCoderequiredFixed Value: OBS
http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.statusCode.coderequiredResult Status
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39
Observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Observation.value:physical-quantity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.value:coded.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.interpretationCoderequiredObservationInterpretation
http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV
http://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0
Observation.referenceRange.observationRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.classCoderequiredActClassObservation
http://terminology.hl7.org/ValueSet/v3-ActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Observation.referenceRange.observationRange.interpretationCoderequiredObservationInterpretation
http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCoderequiredFixed Value: PRCN
http://terminology.hl7.org/ValueSet/v3-ActRelationshipType
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCoderequiredRelationshipConjunction
http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0

Constraints

IdGradePath(s)DetailsRequirements
4537-19212warningObservation.codeThis code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212).
: codeSystem = '2.16.840.1.113883.6.1'
4537-32610warningObservation.value:codedIf Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610).
: codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1'
shall-code-or-nullflavorerrorObservation.codeSHALL contain either a @code attribute or a @nullFlavor attribute, but not both.
: (code | nullFlavor).count() = 1
should-authorwarningObservationSHOULD contain author
: author.exists()
should-interpretationCodewarningObservationSHOULD contain interpretationCode
: interpretationCode.exists()
should-referenceRangewarningObservationSHOULD contain referenceRange
: referenceRange.exists()
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from ResultObservation

Summary

Mandatory: 1 element
Prohibited: 1 element

 

Other representations of profile: CSV, Excel