Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Gender Identity Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/GenderIdentityObservation Version: 2.1
Draft as of 2023-09-29 Computable Name: GenderIdentityObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.34.3.45:2023-05-01

This observation represents the gender identity of the patient, defined as:

“Ones basic sense of being male, female, or other gender (for example, transgender or gender queer). Gender identity can be congruent or incongruent with ones sex assigned at birth based on the appearance of external genitalia. (Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) CommunityA Field Guide, The Joint Commission (2011).)

This template follows the guidelines from the HL7 Gender Harmony project. This template is based on C-CDA Social History Observation template.

This observation is not appropriate for recording patient gender (administrativeGender) or birth sex.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1SocialHistoryObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange, classCode, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:social-history-obs 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.38
..... @extension 1..1stRequired Pattern: 2022-06-01
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1stRequired Pattern: 2023-05-01
... code C1..1CDBinding: Social History Type (preferred)
.... @code 1..1csRequired Pattern: 76691-5
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
.... low 1..1IVXB_TS
.... high 0..1IVXB_TS
... value C1..1CDBinding: Gender Identity USCDI core (required)
.... @nullFlavor 0..1csBinding: Asked but Unknown and Other (preferred)
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by value:act, value:observation, value:typeCode
.... entryRelationship:social-history-entry-sprt-obs 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:social-history-entry-sprt-act 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codepreferredSocial History Type
Observation.statusCoderequiredActStatus
Observation.valuerequiredGender Identity USCDI core
Observation.value.nullFlavorpreferredAsked but Unknown and Other
Observation.entryRelationship:social-history-entry-sprt-obs.typeCoderequiredFixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.typeCoderequiredFixed Value: SPRT

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservation.valueIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
4515-32956errorObservation.codeIf @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:4515-32956).
:
4515-32957errorObservation.valueIf the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1SocialHistoryObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange, classCode, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1bl
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:social-history-obs 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.38
..... @extension 1..1stRequired Pattern: 2022-06-01
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1stRequired Pattern: 2023-05-01
... id 1..*II
... code C1..1CDBinding: Social History Type (preferred)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 76691-5
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @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..*CD
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: completed
.... @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_TS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 1..1IVXB_TS
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value C1..1CDBinding: Gender Identity USCDI core (required)
.... @nullFlavor 0..1csBinding: Asked but Unknown and Other (preferred)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @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..*CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by value:act, value:observation, value:typeCode
.... entryRelationship:social-history-entry-sprt-obs 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AssessmentScaleObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:social-history-entry-sprt-act 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 1..1EntryReferenceBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:social-history-obs.nullFlavorrequiredNullFlavor
Observation.templateId:templateId1.nullFlavorrequiredNullFlavor
Observation.codepreferredSocial History Type
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.effectiveTime.operatorrequiredSetOperator
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuerequiredGender Identity USCDI core
Observation.value.nullFlavorpreferredAsked but Unknown and Other
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavorrequiredNullFlavor
Observation.entryRelationship:social-history-entry-sprt-obs.typeCoderequiredFixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.nullFlavorrequiredNullFlavor
Observation.entryRelationship:social-history-entry-sprt-act.typeCoderequiredFixed Value: SPRT
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservation.valueIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
4515-32956errorObservation.codeIf @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:4515-32956).
:
4515-32957errorObservation.valueIf the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from SocialHistoryObservation

Summary

Mandatory: 7 elements

Differential View

This structure is derived from SocialHistoryObservation

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1SocialHistoryObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange, classCode, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:social-history-obs 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.38
..... @extension 1..1stRequired Pattern: 2022-06-01
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1stRequired Pattern: 2023-05-01
... code C1..1CDBinding: Social History Type (preferred)
.... @code 1..1csRequired Pattern: 76691-5
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
.... low 1..1IVXB_TS
.... high 0..1IVXB_TS
... value C1..1CDBinding: Gender Identity USCDI core (required)
.... @nullFlavor 0..1csBinding: Asked but Unknown and Other (preferred)
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by value:act, value:observation, value:typeCode
.... entryRelationship:social-history-entry-sprt-obs 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:social-history-entry-sprt-act 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codepreferredSocial History Type
Observation.statusCoderequiredActStatus
Observation.valuerequiredGender Identity USCDI core
Observation.value.nullFlavorpreferredAsked but Unknown and Other
Observation.entryRelationship:social-history-entry-sprt-obs.typeCoderequiredFixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.typeCoderequiredFixed Value: SPRT

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservation.valueIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
4515-32956errorObservation.codeIf @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:4515-32956).
:
4515-32957errorObservation.valueIf the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1SocialHistoryObservationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange, classCode, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
... @classCode 1..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1bl
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:social-history-obs 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.38
..... @extension 1..1stRequired Pattern: 2022-06-01
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1stRequired Pattern: 2023-05-01
... id 1..*II
... code C1..1CDBinding: Social History Type (preferred)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 76691-5
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @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..*CD
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: completed
.... @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_TS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 1..1IVXB_TS
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value C1..1CDBinding: Gender Identity USCDI core (required)
.... @nullFlavor 0..1csBinding: Asked but Unknown and Other (preferred)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @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..*CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 1..*EntryRelationshipSlice: Unordered, Open by value:act, value:observation, value:typeCode
.... entryRelationship:social-history-entry-sprt-obs 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AssessmentScaleObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:social-history-entry-sprt-act 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 1..1EntryReferenceBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:social-history-obs.nullFlavorrequiredNullFlavor
Observation.templateId:templateId1.nullFlavorrequiredNullFlavor
Observation.codepreferredSocial History Type
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.effectiveTime.operatorrequiredSetOperator
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuerequiredGender Identity USCDI core
Observation.value.nullFlavorpreferredAsked but Unknown and Other
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavorrequiredNullFlavor
Observation.entryRelationship:social-history-entry-sprt-obs.typeCoderequiredFixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.nullFlavorrequiredNullFlavor
Observation.entryRelationship:social-history-entry-sprt-act.typeCoderequiredFixed Value: SPRT
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservation.valueIf Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM.
:
4515-32956errorObservation.codeIf @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:4515-32956).
:
4515-32957errorObservation.valueIf the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from SocialHistoryObservation

Summary

Mandatory: 7 elements

 

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