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/ProblemObservation | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: ProblemObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2015-08-01 | ||||
This template reflects a discrete observation about a patient’s problem. Because it is a discrete observation, it will have a statusCode of “completed”. The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago.
The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of “UNK”.
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 | Fixed Value: EVN | |
| negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
  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: 2.16.840.1.113883.10.20.22.4.4 | |
  extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: 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). |
| statusCode | 1..1 | CS | ||
 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. | |
| high | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
 value | 1..1 | CD | Binding: Problem (preferred) | |
| code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
 Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
| translation:alt | 0..* | CD | ||
| code | 0..1 | cs | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
 entryRelationship:age | 0..1 | EntryRelationship | ||
 typeCode | 1..1 | cs | 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 | Fixed Value: REFR | |
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| entryRelationship:priority | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:status | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| Observation.value | preferred | Problem |
| 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). : |
| 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 | Fixed Value: EVN | |
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| 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: 2.16.840.1.113883.10.20.22.4.4 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: 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). |
| 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. | |
| high | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| value | 1..1 | CD | Binding: Problem (preferred) | |
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
| translation:alt | 0..* | CD | ||
| @code | 0..1 | cs | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | 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 | |
| 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 | Problem |
| 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 |
| 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()) |
| 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 | Fixed Value: EVN | |
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @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 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: 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). |
| derivationExpr | 0..1 | ST | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| 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. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 1..1 | CD | Binding: Problem (preferred) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
| translation:alt | 0..* | CD | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | ||
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:age | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | AgeObservation | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:priority | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:status | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| referenceRange | 0..* | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| 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 | Problem |
| Observation.value.nullFlavor | required | NullFlavor |
| Observation.value.translation:alt.nullFlavor | required | NullFlavor |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| 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.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 CDAR2.Observation
Summary
Mandatory: 10 elements (5 nested mandatory elements)
Fixed Value: 8 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 | Fixed Value: EVN | |
| negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| 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: 2.16.840.1.113883.10.20.22.4.4 | |
| extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: 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). |
| statusCode | 1..1 | CS | ||
| 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. | |
| high | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| value | 1..1 | CD | Binding: Problem (preferred) | |
| code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
| translation:alt | 0..* | CD | ||
| code | 0..1 | cs | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:age | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | 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 | Fixed Value: REFR | |
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| entryRelationship:priority | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:status | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| Observation.value | preferred | Problem |
| 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). : |
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 | Fixed Value: EVN | |
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| 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: 2.16.840.1.113883.10.20.22.4.4 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: 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). |
| 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. | |
| high | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| value | 1..1 | CD | Binding: Problem (preferred) | |
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
| translation:alt | 0..* | CD | ||
| @code | 0..1 | cs | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | 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 | |
| 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 | Problem |
| 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 |
| 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
| 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 | Fixed Value: EVN | |
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @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 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: 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). |
| derivationExpr | 0..1 | ST | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| 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. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 1..1 | CD | Binding: Problem (preferred) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code | |
| translation:alt | 0..* | CD | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | ||
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:age | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | AgeObservation | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:priority | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:status | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| referenceRange | 0..* | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| 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 | Problem |
| Observation.value.nullFlavor | required | NullFlavor |
| Observation.value.translation:alt.nullFlavor | required | NullFlavor |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| 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.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 CDAR2.Observation
Summary
Mandatory: 10 elements (5 nested mandatory elements)
Fixed Value: 8 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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