Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
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/OutcomeObservation | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: OutcomeObservation | |||
| Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.144 | ||||
This template represents the outcome of care resulting from the interventions used to treat the patient. In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal.
Often thought of as an “actual outcome”, the Outcome Observation may be related to goals, progression toward goals, and the associated interventions. For example, an observation outcome of a blood oxygen saturation level of 95% is related to the goal of “Maintain Pulse Ox greater than 92”, which in turn is related to the health concern of respiratory insufficiency and the problem of pneumonia. The template makes use of the Entry Reference (templateId:2.16.840.1.113883.10.20.22.4.122) to reference the interventions and goals defined elsewhere in the Care Plan CDA instance.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | C | 1..1 | CDAR2.Observation | 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 Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
 classCode | 1..1 | cs | Fixed Value: OBS | |
| moodCode | 1..1 | cs | Fixed Value: EVN | |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
  extension | 0..0 | |||
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| value | 0..1 | ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | ||
 author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation | |
 entryRelationship:entryReference | C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
 typeCode | 1..1 | cs | Fixed Value: GEVL | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | 0..1 | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. | |
| typeCode | 1..1 | cs | Fixed Value: SPRT | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference2 | C | 0..* | EntryRelationship | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| act | 1..1 | EntryReference | Base for all types and resources | |
 reference | 0..* | Reference | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
 externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference2 | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | 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 Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
 @classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
 value | 0..1 | |||
 value | ANY | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:entryReference | C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: GEVL | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | 0..1 | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference2 | C | 0..* | EntryRelationship | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Reference | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.code | extensible | ObservationType |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: GEVL |
| Observation.entryRelationship:progressTowardGoalObservation.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:entryReference2.typeCode | required | Fixed Value: RSON |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference2 | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : | |
| 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.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.entryRelationship:entryReference.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: GEVL |
| Observation.entryRelationship:progressTowardGoalObservation.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:progressTowardGoalObservation.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:entryReference2.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:entryReference2.typeCode | required | Fixed Value: RSON |
| Observation.reference.nullFlavor | required | NullFlavor |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| Observation.referenceRange.nullFlavor | required | NullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference2 | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : | |
| 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 CDAR2.Observation
Summary
Mandatory: 4 elements (5 nested mandatory elements)
Fixed Value: 7 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | 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 Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
| classCode | 1..1 | cs | Fixed Value: OBS | |
| moodCode | 1..1 | cs | Fixed Value: EVN | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| extension | 0..0 | |||
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| value | 0..1 | ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:entryReference | C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| typeCode | 1..1 | cs | Fixed Value: GEVL | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | 0..1 | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. | |
| typeCode | 1..1 | cs | Fixed Value: SPRT | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference2 | C | 0..* | EntryRelationship | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Reference | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference2 | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | 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 Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| value | 0..1 | |||
| value | ANY | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:entryReference | C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: GEVL | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | 0..1 | EntryRelationship | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference2 | C | 0..* | EntryRelationship | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Reference | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.code | extensible | ObservationType |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: GEVL |
| Observation.entryRelationship:progressTowardGoalObservation.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:entryReference2.typeCode | required | Fixed Value: RSON |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference2 | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : | |
| 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.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.entryRelationship:entryReference.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: GEVL |
| Observation.entryRelationship:progressTowardGoalObservation.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:progressTowardGoalObservation.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:entryReference2.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:entryReference2.typeCode | required | Fixed Value: RSON |
| Observation.reference.nullFlavor | required | NullFlavor |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| Observation.referenceRange.nullFlavor | required | NullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference2 | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : | |
| 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 CDAR2.Observation
Summary
Mandatory: 4 elements (5 nested mandatory elements)
Fixed Value: 7 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
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