Consolidated CDA Release 2.1 StructureDefinition Publication
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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: Vital Sign Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignObservation Version: 2.1
Draft as of 2023-09-29 Computable Name: VitalSignObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09

This template represents measurement of common vital signs. Vital signs are represented with additional vocabulary constraints for type of vital sign and unit of measure.

The following is a list of recommended units for common types of vital sign measurements:

Name Unit
PulseOx %
Height/Head Circumf cm
Weight kg
Temp Cel
BP mm[Hg]
Pulse/Resp Rate /min
BMI kg/m2
BSA m2
inhaled oxygen concentration %

Usage:

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 CDAR2.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
... classCode 1..1csFixed Value: OBS
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.27
..... extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CD
.... code 0..1csBinding: Vital Sign Result Type (preferred)
... statusCode 1..1CS
.... code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1PQ
.... unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... interpretationCode 0..1CE
.... code 1..1csBinding: Observation Interpretation (HL7) (required)
... methodCode 0..1CE
... targetSiteCode 0..1CD
... author 0..*AuthorParticipationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.code.codepreferredVital Sign Result Type
Observation.value.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
Observation.interpretationCode.coderequiredObservation Interpretation (HL7)
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:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.27
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CDBinding: ObservationType (extensible)
.... @code 0..1csBinding: Vital Sign Result Type (preferred)
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1PQ
.... @unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... interpretationCode 0..1CEBinding: ObservationInterpretation (required)
.... @code 1..1csBinding: Observation Interpretation (HL7) (required)
... methodCode 0..1CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..1CD
... author 0..*AuthorParticipationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codeextensibleObservationType
Observation.code.codepreferredVital Sign Result Type
Observation.statusCoderequiredActStatus
Observation.value.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.coderequiredObservation Interpretation (HL7)
Observation.methodCodeextensibleObservationMethod

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:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.27
..... @extension 1..1stRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1csBinding: Vital Sign Result Type (preferred)
.... @codeSystem 0..1oid, uuid, ruid
.... @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
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1PQ
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
.... @value 0..1real
.... translation 0..*PQR
... interpretationCode 0..1CEBinding: ObservationInterpretation (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csBinding: Observation Interpretation (HL7) (required)
.... @codeSystem 0..1oid, uuid, ruid
.... @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
.... translation 0..*CD
... methodCode 0..1CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..1CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase 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..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:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.code.codepreferredVital Sign Result Type
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.value.nullFlavorrequiredNullFlavor
Observation.value.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredNullFlavor
Observation.interpretationCode.coderequiredObservation Interpretation (HL7)
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: 10 elements (1 nested mandatory element)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation CDAR2.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
... classCode 1..1csFixed Value: OBS
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.27
..... extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CD
.... code 0..1csBinding: Vital Sign Result Type (preferred)
... statusCode 1..1CS
.... code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1PQ
.... unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... interpretationCode 0..1CE
.... code 1..1csBinding: Observation Interpretation (HL7) (required)
... methodCode 0..1CE
... targetSiteCode 0..1CD
... author 0..*AuthorParticipationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.code.codepreferredVital Sign Result Type
Observation.value.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
Observation.interpretationCode.coderequiredObservation Interpretation (HL7)

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:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.27
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CDBinding: ObservationType (extensible)
.... @code 0..1csBinding: Vital Sign Result Type (preferred)
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: completed
... effectiveTime 1..1IVL_TS
... value 1..1PQ
.... @unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... interpretationCode 0..1CEBinding: ObservationInterpretation (required)
.... @code 1..1csBinding: Observation Interpretation (HL7) (required)
... methodCode 0..1CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..1CD
... author 0..*AuthorParticipationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredFixed Value: OBS
Observation.codeextensibleObservationType
Observation.code.codepreferredVital Sign Result Type
Observation.statusCoderequiredActStatus
Observation.value.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.coderequiredObservation Interpretation (HL7)
Observation.methodCodeextensibleObservationMethod

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:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.27
..... @extension 1..1stRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1csBinding: Vital Sign Result Type (preferred)
.... @codeSystem 0..1oid, uuid, ruid
.... @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
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1PQ
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
.... @value 0..1real
.... translation 0..*PQR
... interpretationCode 0..1CEBinding: ObservationInterpretation (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csBinding: Observation Interpretation (HL7) (required)
.... @codeSystem 0..1oid, uuid, ruid
.... @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
.... translation 0..*CD
... methodCode 0..1CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..1CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase 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..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:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.code.codepreferredVital Sign Result Type
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.value.nullFlavorrequiredNullFlavor
Observation.value.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredNullFlavor
Observation.interpretationCode.coderequiredObservation Interpretation (HL7)
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: 10 elements (1 nested mandatory element)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel