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/PlannedObservation | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: PlannedObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09 | ||||
This template represents planned observations that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM, i.e., procedures alter the patient’s body. Examples of these observations are laboratory tests, diagnostic imaging tests, EEGs, and EKGs.
The importance of the planned observation to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the observation is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Observation template may also indicate the potential insurance coverage for the observation.
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 | 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 | ||
 classCode | 1..1 | cs | Fixed Value: OBS | |
| moodCode | 1..1 | cs | Binding: Planned moodCode (Observation) (required) | |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.44 | |
  extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| statusCode | 1..1 | CS | ||
 code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned observation represents the time that the observation should occur. | |
| 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 | ||
| methodCode | 0..1 | CE | In a planned observation the provider may suggest that an observation should be performed using a particular method. | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned observation. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the observation could be identified using procedure/performer. | |
 author | 0..* | AuthorParticipation | The author in a planned observation represents the clinician who is requesting or planning the observation. | |
 Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the observation. Slice: Unordered, Open by profile:observation, profile:act | |
 entryRelationship:priorityPreference | 0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the observation. | |
 typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | 0..* | EntryRelationship | The following entryRelationship represents the indication for the observation. | |
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned observation. | |
| typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.moodCode | required | Planned moodCode (Observation) |
| Observation.targetSiteCode | required | Body Site Value Set |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 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 | |
 @classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Binding: Planned moodCode (Observation) (required) | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.44 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned observation represents the time that the observation should occur. | |
 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 | |||
| methodCode | 0..1 | CE | In a planned observation the provider may suggest that an observation should be performed using a particular method. Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned observation. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the observation could be identified using procedure/performer. | |
| author | 0..* | AuthorParticipation | The author in a planned observation represents the clinician who is requesting or planning the observation. | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the observation. Slice: Unordered, Open by profile:observation, profile:act | |
| entryRelationship:priorityPreference | 0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the observation. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | 0..* | EntryRelationship | The following entryRelationship represents the indication for the observation. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned observation. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Planned moodCode (Observation) |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode | required | Body Site Value Set |
| Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Observation.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:plannedCoverage.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| 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.moodCode | required | Planned moodCode (Observation) |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| 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.targetSiteCode | required | Body Site Value Set |
| Observation.entryRelationship:priorityPreference.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:indication.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Observation.entryRelationship:instruction.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:plannedCoverage.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:plannedCoverage.typeCode | required | Fixed Value: COMP |
| Observation.referenceRange.nullFlavor | required | NullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 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: 7 elements (4 nested mandatory elements)
Fixed Value: 6 elements
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 | 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 | ||
| classCode | 1..1 | cs | Fixed Value: OBS | |
| moodCode | 1..1 | cs | Binding: Planned moodCode (Observation) (required) | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.44 | |
| extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| statusCode | 1..1 | CS | ||
| code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned observation represents the time that the observation should occur. | |
| 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 | ||
| methodCode | 0..1 | CE | In a planned observation the provider may suggest that an observation should be performed using a particular method. | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned observation. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the observation could be identified using procedure/performer. | |
| author | 0..* | AuthorParticipation | The author in a planned observation represents the clinician who is requesting or planning the observation. | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the observation. Slice: Unordered, Open by profile:observation, profile:act | |
| entryRelationship:priorityPreference | 0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the observation. | |
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | 0..* | EntryRelationship | The following entryRelationship represents the indication for the observation. | |
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned observation. | |
| typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.moodCode | required | Planned moodCode (Observation) |
| Observation.targetSiteCode | required | Body Site Value Set |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 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 | |
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Binding: Planned moodCode (Observation) (required) | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.44 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned observation represents the time that the observation should occur. | |
| 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 | |||
| methodCode | 0..1 | CE | In a planned observation the provider may suggest that an observation should be performed using a particular method. Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned observation. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the observation could be identified using procedure/performer. | |
| author | 0..* | AuthorParticipation | The author in a planned observation represents the clinician who is requesting or planning the observation. | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the observation. Slice: Unordered, Open by profile:observation, profile:act | |
| entryRelationship:priorityPreference | 0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the observation. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | 0..* | EntryRelationship | The following entryRelationship represents the indication for the observation. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned observation. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Planned moodCode (Observation) |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode | required | Body Site Value Set |
| Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Observation.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:plannedCoverage.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| 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.moodCode | required | Planned moodCode (Observation) |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| 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.targetSiteCode | required | Body Site Value Set |
| Observation.entryRelationship:priorityPreference.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:indication.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Observation.entryRelationship:instruction.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:plannedCoverage.nullFlavor | required | NullFlavor |
| Observation.entryRelationship:plannedCoverage.typeCode | required | Fixed Value: COMP |
| Observation.referenceRange.nullFlavor | required | NullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 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: 7 elements (4 nested mandatory elements)
Fixed Value: 6 elements
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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