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

## Logical Model: Result Observation

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:

- Use this Logical Model: Health Concern Act, Result Organizer and Risk Concern Act

### Formal Views of Profile Content

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

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

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..&ast;] 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

#### Terminology Bindings (Differential)

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

#### Constraints

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..&ast;] 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..&ast;] 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

#### Terminology Bindings

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

#### Constraints

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..&ast;] 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..&ast;] 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

#### Terminology Bindings

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

#### Constraints

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..&ast;] 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:

- Author Participation (http://hl7.org/cda/us/ccda/StructureDefinition/AuthorParticipation)

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

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..&ast;] 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

#### Terminology Bindings (Differential)

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

#### Constraints

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..&ast;] 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..&ast;] 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

#### Terminology Bindings

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

#### Constraints

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..&ast;] 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..&ast;] 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

#### Terminology Bindings

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

#### Constraints

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..&ast;] 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:

- Author Participation (http://hl7.org/cda/us/ccda/StructureDefinition/AuthorParticipation)

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