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
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/LongitudinalCareWoundObservation | Version: 2.1 | |||
Draft as of 2023-09-29 | Computable Name: LongitudinalCareWoundObservation | |||
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.114:2015-08-01 |
This template represents acquired or surgical wounds and is not intended to encompass all wound types. The template applies to wounds such as pressure ulcers, surgical incisions, and deep tissue injury wounds. Information in this template may include information about the wound measurements characteristics.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ProblemObservation
Path | Conformance | ValueSet |
Observation.value | preferred | Wound Type |
Observation.targetSiteCode | preferred | Body Site Value Set |
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | ProblemObservation | XML 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship Base for all types and resources | |
@classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
templateId:secondary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) |
@code | 1..1 | cs | Required Pattern: ASSERTION | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
value | 1..1 | CD | Binding: Wound Type (preferred) | |
Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
translation:alt | 0..* | CD | ||
targetSiteCode | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
name | 1..1 | CV | ||
@code | 1..1 | cs | Required Pattern: 272741003 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96 | |
value | 1..1 | CD | ||
@code | 1..1 | cs | Binding: TargetSite Qualifiers (preferred) | |
author | 0..* | AuthorParticipation | Base for all types and resources | |
Slices for entryRelationship | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation | |
entryRelationship:age | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
@inversionInd | 1..1 | bl | Fixed Value: true | |
observation | 1..1 | AgeObservation | Base for all types and resources | |
entryRelationship:prognosis | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
observation | 1..1 | PrognosisObservation | Base for all types and resources | |
entryRelationship:priority | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
observation | 1..1 | PriorityPreference | Base for all types and resources | |
entryRelationship:status | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
observation | 1..1 | ProblemStatus | Base for all types and resources | |
entryRelationship:woundMeasurementObservation | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | WoundMeasurementObservation | Base for all types and resources | |
entryRelationship:woundCharacteristic | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | WoundCharacteristic | Base for all types and resources | |
entryRelationship:numberofPressureUlcersObservation | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. | |
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | NumberofPressureUlcersObservation | Base for all types and resources | |
entryRelationship:highestPressureUlcerStage | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | HighestPressureUlcerStage | Base for all types and resources | |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.code | preferred | Problem Type (SNOMEDCT) |
Observation.statusCode | required | ActStatus |
Observation.value | preferred | Wound Type |
Observation.targetSiteCode | preferred | Body Site Value Set |
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers |
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP |
Id | Grade | Path(s) | Details | Requirements |
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.templateId:primary.nullFlavor | required | NullFlavor |
Observation.templateId:secondary.nullFlavor | required | NullFlavor |
Observation.code | preferred | Problem Type (SNOMEDCT) |
Observation.code.nullFlavor | required | NullFlavor |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.effectiveTime.nullFlavor | required | NullFlavor |
Observation.effectiveTime.operator | required | SetOperator |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Observation.value | preferred | Wound Type |
Observation.value.nullFlavor | required | NullFlavor |
Observation.value.translation:alt.nullFlavor | required | NullFlavor |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | extensible | ObservationMethod |
Observation.targetSiteCode | preferred | Body Site Value Set |
Observation.targetSiteCode.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.name.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.value.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers |
Observation.entryRelationship:age.nullFlavor | required | NullFlavor |
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
Observation.entryRelationship:prognosis.nullFlavor | required | NullFlavor |
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:priority.nullFlavor | required | NullFlavor |
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:status.nullFlavor | required | NullFlavor |
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:woundMeasurementObservation.nullFlavor | required | NullFlavor |
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:woundCharacteristic.nullFlavor | required | NullFlavor |
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:numberofPressureUlcersObservation.nullFlavor | required | NullFlavor |
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:highestPressureUlcerStage.nullFlavor | required | NullFlavor |
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP |
Observation.referenceRange.nullFlavor | required | NullFlavor |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path(s) | Details | Requirements |
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from ProblemObservation
Summary
Mandatory: 5 elements (9 nested mandatory elements)
Fixed Value: 4 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from ProblemObservation
Path | Conformance | ValueSet |
Observation.value | preferred | Wound Type |
Observation.targetSiteCode | preferred | Body Site Value Set |
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | ProblemObservation | XML 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship Base for all types and resources | |
@classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
templateId:secondary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) |
@code | 1..1 | cs | Required Pattern: ASSERTION | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
value | 1..1 | CD | Binding: Wound Type (preferred) | |
Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
translation:alt | 0..* | CD | ||
targetSiteCode | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
name | 1..1 | CV | ||
@code | 1..1 | cs | Required Pattern: 272741003 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96 | |
value | 1..1 | CD | ||
@code | 1..1 | cs | Binding: TargetSite Qualifiers (preferred) | |
author | 0..* | AuthorParticipation | Base for all types and resources | |
Slices for entryRelationship | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation | |
entryRelationship:age | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
@inversionInd | 1..1 | bl | Fixed Value: true | |
observation | 1..1 | AgeObservation | Base for all types and resources | |
entryRelationship:prognosis | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
observation | 1..1 | PrognosisObservation | Base for all types and resources | |
entryRelationship:priority | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
observation | 1..1 | PriorityPreference | Base for all types and resources | |
entryRelationship:status | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
observation | 1..1 | ProblemStatus | Base for all types and resources | |
entryRelationship:woundMeasurementObservation | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | WoundMeasurementObservation | Base for all types and resources | |
entryRelationship:woundCharacteristic | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | WoundCharacteristic | Base for all types and resources | |
entryRelationship:numberofPressureUlcersObservation | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. | |
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | NumberofPressureUlcersObservation | Base for all types and resources | |
entryRelationship:highestPressureUlcerStage | 0..1 | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | HighestPressureUlcerStage | Base for all types and resources | |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.code | preferred | Problem Type (SNOMEDCT) |
Observation.statusCode | required | ActStatus |
Observation.value | preferred | Wound Type |
Observation.targetSiteCode | preferred | Body Site Value Set |
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers |
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP |
Id | Grade | Path(s) | Details | Requirements |
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.templateId:primary.nullFlavor | required | NullFlavor |
Observation.templateId:secondary.nullFlavor | required | NullFlavor |
Observation.code | preferred | Problem Type (SNOMEDCT) |
Observation.code.nullFlavor | required | NullFlavor |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.effectiveTime.nullFlavor | required | NullFlavor |
Observation.effectiveTime.operator | required | SetOperator |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Observation.value | preferred | Wound Type |
Observation.value.nullFlavor | required | NullFlavor |
Observation.value.translation:alt.nullFlavor | required | NullFlavor |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | extensible | ObservationMethod |
Observation.targetSiteCode | preferred | Body Site Value Set |
Observation.targetSiteCode.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.name.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.value.nullFlavor | required | NullFlavor |
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers |
Observation.entryRelationship:age.nullFlavor | required | NullFlavor |
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
Observation.entryRelationship:prognosis.nullFlavor | required | NullFlavor |
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:priority.nullFlavor | required | NullFlavor |
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:status.nullFlavor | required | NullFlavor |
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
Observation.entryRelationship:woundMeasurementObservation.nullFlavor | required | NullFlavor |
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:woundCharacteristic.nullFlavor | required | NullFlavor |
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:numberofPressureUlcersObservation.nullFlavor | required | NullFlavor |
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP |
Observation.entryRelationship:highestPressureUlcerStage.nullFlavor | required | NullFlavor |
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP |
Observation.referenceRange.nullFlavor | required | NullFlavor |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path(s) | Details | Requirements |
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from ProblemObservation
Summary
Mandatory: 5 elements (9 nested mandatory elements)
Fixed Value: 4 elements
Structures
This structure refers to these other structures: