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/ResultObservation | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: ResultObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2023-05-01 | ||||
This template represents the results of a laboratory, radiology, or other study performed on a patient.
The result observation includes a statusCode to allow recording the status of an observation. Pending results (e.g., a test has been run but results have not been reported yet) should be represented as active ActStatus.
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 | |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:templateId1 | 1..1 | II | templateId | |
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
  extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). |
| statusCode | 1..1 | CS | ||
 code | 1..1 | cs | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| value | C | 1..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 | 4537-31484: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. 4537-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). |
| interpretationCode | 0..* | CE | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | ||
| targetSiteCode | 0..1 | CD | ||
| specimen | 0..* | Specimen | ||
 specimenRole | 1..1 | SpecimenRole | ||
| specimenPlayingEntity | 1..1 | PlayingEntity | ||
| code | 1..1 | CE | Binding: VSAC 2.16.840.1.113762.1.4.1099.54 (preferred) | |
 author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | InfrastructureRoot | ||
| observationRange | 1..1 | ObservationRange | ||
| code | 0..0 | |||
| value | 1..1 | 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 | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode | required | Observation Interpretation (HL7) |
| Observation.specimen.specimenRole.specimenPlayingEntity.code | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.54 |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : | |
| 4537-31484 | warning | Observation.value | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4537-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). : | |
| 4537-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). : |
| 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 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:templateId1 | 1..1 | II | templateId | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
 value | C | 1..1 | 4537-31484: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. 4537-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). | |
 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 | |||
| interpretationCode | 0..* | CE | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | CD | ||
| specimen | 0..* | Specimen | ||
| specimenRole | 1..1 | SpecimenRole | ||
| specimenPlayingEntity | 1..1 | PlayingEntity | ||
| @classCode | 1..1 | cs | Binding: EntityClassRoot (required) | |
| code | 1..1 | CE | Binding: VSAC 2.16.840.1.113762.1.4.1099.54 (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | InfrastructureRoot | ||
| observationRange | 1..1 | ObservationRange | ||
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| value | 1..1 | |||
| 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 | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode | required | Observation Interpretation (HL7) |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.specimen.specimenRole.specimenPlayingEntity.classCode | required | EntityClassRoot |
| Observation.specimen.specimenRole.specimenPlayingEntity.code | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.54 |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : | |
| 4537-31484 | warning | Observation.value | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4537-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). : | |
| 4537-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). : | |
| 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 | ||
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:templateId1 | 1..1 | II | templateId | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). |
| 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 | Binding: Result Status (required) | |
| @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 | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | C | 1..1 | 4537-31484: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. 4537-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). | |
| 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 | |||
| interpretationCode | 0..* | CE | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | CD | ||
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetDirect (required) Fixed Value: SPC | |
| specimenRole | 1..1 | SpecimenRole | ||
| @classCode | 0..1 | cs | Binding: RoleClassSpecimen (required) Fixed Value: SPEC | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| specimenPlayingEntity | 1..1 | PlayingEntity | ||
| @classCode | 1..1 | cs | Binding: EntityClassRoot (required) | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 1..1 | CE | Binding: VSAC 2.16.840.1.113762.1.4.1099.54 (preferred) | |
| quantity | 0..* | PQ | ||
| name | 0..* | PN | ||
| sdtcBirthTime | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc | 0..1 | ED | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| entryRelationship | 0..* | EntryRelationship | ||
| 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 | ||
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| templateId | 0..* | II | ||
| text | 0..1 | ED | ||
| value | 1..1 | |||
| 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 | |||
| interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.templateId:templateId1.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| Observation.statusCode.code | required | Result Status |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | Observation Interpretation (HL7) |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.specimen.nullFlavor | required | NullFlavor |
| Observation.specimen.typeCode | required | Fixed Value: SPC |
| Observation.specimen.specimenRole.classCode | required | Fixed Value: SPEC |
| Observation.specimen.specimenRole.specimenPlayingEntity.classCode | required | EntityClassRoot |
| Observation.specimen.specimenRole.specimenPlayingEntity.determinerCode | required | Fixed Value: INSTANCE |
| Observation.specimen.specimenRole.specimenPlayingEntity.code | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.54 |
| Observation.referenceRange.nullFlavor | required | NullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
| Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : | |
| 4537-31484 | warning | Observation.value | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4537-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). : | |
| 4537-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). : | |
| 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: 9 elements (3 nested mandatory elements)
Fixed Value: 2 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 | 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 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:templateId1 | 1..1 | II | templateId | |
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | cs | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| value | C | 1..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 | 4537-31484: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. 4537-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). |
| interpretationCode | 0..* | CE | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | ||
| targetSiteCode | 0..1 | CD | ||
| specimen | 0..* | Specimen | ||
| specimenRole | 1..1 | SpecimenRole | ||
| specimenPlayingEntity | 1..1 | PlayingEntity | ||
| code | 1..1 | CE | Binding: VSAC 2.16.840.1.113762.1.4.1099.54 (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | InfrastructureRoot | ||
| observationRange | 1..1 | ObservationRange | ||
| code | 0..0 | |||
| value | 1..1 | 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 | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode | required | Observation Interpretation (HL7) |
| Observation.specimen.specimenRole.specimenPlayingEntity.code | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.54 |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : | |
| 4537-31484 | warning | Observation.value | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4537-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). : | |
| 4537-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). : |
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 | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:templateId1 | 1..1 | II | templateId | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| value | C | 1..1 | 4537-31484: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. 4537-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). | |
| 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 | |||
| interpretationCode | 0..* | CE | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | CD | ||
| specimen | 0..* | Specimen | ||
| specimenRole | 1..1 | SpecimenRole | ||
| specimenPlayingEntity | 1..1 | PlayingEntity | ||
| @classCode | 1..1 | cs | Binding: EntityClassRoot (required) | |
| code | 1..1 | CE | Binding: VSAC 2.16.840.1.113762.1.4.1099.54 (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | InfrastructureRoot | ||
| observationRange | 1..1 | ObservationRange | ||
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| value | 1..1 | |||
| 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 | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode | required | Observation Interpretation (HL7) |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.specimen.specimenRole.specimenPlayingEntity.classCode | required | EntityClassRoot |
| Observation.specimen.specimenRole.specimenPlayingEntity.code | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.54 |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : | |
| 4537-31484 | warning | Observation.value | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4537-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). : | |
| 4537-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). : | |
| 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 | ||
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:templateId1 | 1..1 | II | templateId | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). |
| 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 | Binding: Result Status (required) | |
| @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 | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | C | 1..1 | 4537-31484: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. 4537-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). | |
| 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 | |||
| interpretationCode | 0..* | CE | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | CD | ||
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetDirect (required) Fixed Value: SPC | |
| specimenRole | 1..1 | SpecimenRole | ||
| @classCode | 0..1 | cs | Binding: RoleClassSpecimen (required) Fixed Value: SPEC | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| specimenPlayingEntity | 1..1 | PlayingEntity | ||
| @classCode | 1..1 | cs | Binding: EntityClassRoot (required) | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 1..1 | CE | Binding: VSAC 2.16.840.1.113762.1.4.1099.54 (preferred) | |
| quantity | 0..* | PQ | ||
| name | 0..* | PN | ||
| sdtcBirthTime | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc | 0..1 | ED | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| entryRelationship | 0..* | EntryRelationship | ||
| 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 | ||
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| templateId | 0..* | II | ||
| text | 0..1 | ED | ||
| value | 1..1 | |||
| 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 | |||
| interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.templateId:templateId1.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| Observation.statusCode.code | required | Result Status |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | Observation Interpretation (HL7) |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.specimen.nullFlavor | required | NullFlavor |
| Observation.specimen.typeCode | required | Fixed Value: SPC |
| Observation.specimen.specimenRole.classCode | required | Fixed Value: SPEC |
| Observation.specimen.specimenRole.specimenPlayingEntity.classCode | required | EntityClassRoot |
| Observation.specimen.specimenRole.specimenPlayingEntity.determinerCode | required | Fixed Value: INSTANCE |
| Observation.specimen.specimenRole.specimenPlayingEntity.code | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.54 |
| Observation.referenceRange.nullFlavor | required | NullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
| Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : | |
| 4537-31484 | warning | Observation.value | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4537-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:4537-31866). : | |
| 4537-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:4537-32610). : | |
| 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: 9 elements (3 nested mandatory elements)
Fixed Value: 2 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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