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

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

Logical Model: Reason

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/Reason Version: 2.1
Draft as of 2023-09-29 Computable Name: Reason
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.24.3.88:2023-05-01

This template describes the thought process or justification for an action or for not performing an action. Examples include patient, system, or non-problem/diagnosis medical-related reasons for declining to perform specific actions, or any reason for performing an action. Note that the parent template that calls this template can be asserted to have occurred or to not have occurred. Therefore, this template simply adds a reason to some other (possibly negated) act. As such, there is nothing in this template that says whether the parent act did or did not occur. It is expected that the primary use of this template within C-CDA is to provide the rationale for why something was not done. If this template is called by a template that is not negated, the Reason template should contain something other than a problem or a diagnosis, such as a patient preference. The Indication observation: 2.16.840.1.113883.10.20.22.4.19 should be used to represent a diagnosis or problem to indicate the diagnosis or problem is the rationale for an action. Immunization Refusal Reason: 2.16.840.1.113883.10.20.22.4.53 should be used to represent the rationale for the patient declining an immunization as the value set is crafted for the immunization use case.

Usage:

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

Formal Views of Profile Content

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

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML 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..1csFixed Value: OBS
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.24.3.88
..... extension 1..1stRequired Pattern: 2023-05-01
... code 1..1CD
.... code 1..1csRequired Pattern: 77301-0
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CS
.... code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
.... low 1..1IVXB_TS
.... high 0..1IVXB_TS
... value 1..1CD

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML 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..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @extension 1..1stRequired Pattern: 2023-05-01
... code 1..1CDBinding: ObservationType (extensible)
.... @code 1..1csRequired Pattern: 77301-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
.... low 1..1IVXB_TS
.... high 0..1IVXB_TS
... value 1..1CD

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML 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..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1bl
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @extension 1..1stRequired Pattern: 2023-05-01
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 77301-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: completed
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 1..1IVXB_TS
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:templateId1.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.effectiveTime.operatorrequiredSetOperator
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Observation

Summary

Mandatory: 12 elements
Fixed Value: 3 elements

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML 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..1csFixed Value: OBS
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.24.3.88
..... extension 1..1stRequired Pattern: 2023-05-01
... code 1..1CD
.... code 1..1csRequired Pattern: 77301-0
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CS
.... code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
.... low 1..1IVXB_TS
.... high 0..1IVXB_TS
... value 1..1CD

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML 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..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @extension 1..1stRequired Pattern: 2023-05-01
... code 1..1CDBinding: ObservationType (extensible)
.... @code 1..1csRequired Pattern: 77301-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
.... low 1..1IVXB_TS
.... high 0..1IVXB_TS
... value 1..1CD

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationXML 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..1csBinding: ActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1csFixed Value: EVN
... @negationInd 0..1bl
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @extension 1..1stRequired Pattern: 2023-05-01
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 77301-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: completed
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 1..1IVXB_TS
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.templateId:templateId1.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.effectiveTime.operatorrequiredSetOperator
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.referenceRange.nullFlavorrequiredNullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Observation

Summary

Mandatory: 12 elements
Fixed Value: 3 elements

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension

 

Other representations of profile: CSV, Excel