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: Assessment Scale Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation | Version: 2.1
Draft as of 2023-09-29 | Computable Name: AssessmentScaleObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.69:2022-06-01

An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), Glasgow Coma Scale (assesses coma and impaired consciousness), and WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education - a clinic-based screening and referral system developed for pediatric settings).

When an Assessment Scale Observation is contained in a Problem Observation, a Social History Observation or a Procedure instance that is Social Determinant of Health focused, that Assessment scale MAY contain assessment scale observations that represent question and answer pairs from SDOH screening instruments that are represented in LOINC. Note that guidance on the use of LOINC in assessment scales already exists in Assessment Scale Observation constraints and Assessment Scale Supporting Observations constraints.

Usage:

- Use this Logical Model: Disability Status Observation, Functional Status Observation, Functional Status Section, Health Concern Act... Show 7 more, Mental Status Observation, Mental Status Section, Planned Procedure, Procedure Activity Procedure, Risk Concern Act, Sensory Status and Social History Observation

### 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: 2.16.840.1.113883.10.20.22.4.69
extension |  | 1..1 | st | Required Pattern: 2022-06-01
id |  | 1..* | II |
code |  | 1..1 | CD |
derivationExpr |  | 0..1 | ST |
statusCode |  | 1..1 | CS |
code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value |  | 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 |
interpretationCode |  | 0..* | CE |
translation |  | 0..* | CD |
author |  | 0..* | Author |
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:observation, value:typeCode
entryRelationship:entryRelationship1 |  | 0..* | EntryRelationship | entryRelationship
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources
referenceRange |  | 0..* | InfrastructureRoot |
observationRange |  | 1..1 | ObservationRange |
text |  | 0..1 | ED |
reference |  | 0..1 | TEL |
value | C | 0..1 | url | 4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
Documentation for this format

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-16804 | error | Observation.referenceRange.observationRange.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804). : |

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: 2.16.840.1.113883.10.20.22.4.69
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: ObservationType (extensible)
derivationExpr |  | 0..1 | ST |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value |  | 1..1 |  |
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: ObservationInterpretation (required)
translation |  | 0..* | CD |
author |  | 0..* | Author |
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:observation, value:typeCode
entryRelationship:entryRelationship1 |  | 0..* | EntryRelationship | entryRelationship
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources
referenceRange |  | 0..* | InfrastructureRoot |
observationRange |  | 1..1 | ObservationRange |
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required)
text |  | 0..1 | ED |
reference |  | 0..1 | TEL |
@value | C | 0..1 | url | 4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
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.interpretationCode | required | ObservationInterpretation
Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: COMP
Observation.referenceRange.observationRange.classCode | required | ActClassObservation

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-16804 | error | Observation.referenceRange.observationRange.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804). : |
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: 2.16.840.1.113883.10.20.22.4.69
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: ObservationType (extensible)
derivationExpr |  | 0..1 | ST |
text |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime |  | 1..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 1..1 |  |
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: ObservationInterpretation (required)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs |
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:observation, value:typeCode
entryRelationship:entryRelationship1 |  | 0..* | EntryRelationship | entryRelationship
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
referenceRange |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipPertains (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required)
@moodCode |  | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT
templateId |  | 0..* | II |
code |  | 0..1 | CD | Binding: v3 Code System ActCode (extensible)
text |  | 0..1 | ED |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@charset |  | 0..1 | cs |
@compression |  | 0..1 | cs | Binding: CompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs |
@representation |  | 0..1 | cs |
data[x] |  | 0..1 |  |
dataString |  |  | string(st) |
dataBase64Binary |  |  | base64Binary(bin) |
reference |  | 0..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | url | 4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..* | cs | Binding: AddressUse (required)
thumbnail |  | 0..1 | ED |
value |  | 0..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.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Observation.interpretationCode | required | ObservationInterpretation
Observation.interpretationCode.nullFlavor | required | NullFlavor
Observation.methodCode | extensible | ObservationMethod
Observation.entryRelationship:entryRelationship1.nullFlavor | required | NullFlavor
Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: COMP
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.code | extensible | ActCode
Observation.referenceRange.observationRange.text.nullFlavor | required | NullFlavor
Observation.referenceRange.observationRange.text.compression | required | CompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm
Observation.referenceRange.observationRange.text.reference.nullFlavor | required | NullFlavor
Observation.referenceRange.observationRange.text.reference.use | required | AddressUse
Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-16804 | error | Observation.referenceRange.observationRange.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804). : |
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 (1 nested mandatory element)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

- Assessment Scale Supporting Observation (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleSupportingObservation)

Slices

This structure defines the following Slices:

- The element Observation.templateId is sliced based on the values of value:root, value:extension
- The element Observation.entryRelationship is sliced based on the values of value:observation, value:typeCode

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: 2.16.840.1.113883.10.20.22.4.69
extension |  | 1..1 | st | Required Pattern: 2022-06-01
id |  | 1..* | II |
code |  | 1..1 | CD |
derivationExpr |  | 0..1 | ST |
statusCode |  | 1..1 | CS |
code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value |  | 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 |
interpretationCode |  | 0..* | CE |
translation |  | 0..* | CD |
author |  | 0..* | Author |
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:observation, value:typeCode
entryRelationship:entryRelationship1 |  | 0..* | EntryRelationship | entryRelationship
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources
referenceRange |  | 0..* | InfrastructureRoot |
observationRange |  | 1..1 | ObservationRange |
text |  | 0..1 | ED |
reference |  | 0..1 | TEL |
value | C | 0..1 | url | 4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
Documentation for this format

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-16804 | error | Observation.referenceRange.observationRange.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804). : |

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: 2.16.840.1.113883.10.20.22.4.69
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: ObservationType (extensible)
derivationExpr |  | 0..1 | ST |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value |  | 1..1 |  |
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: ObservationInterpretation (required)
translation |  | 0..* | CD |
author |  | 0..* | Author |
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:observation, value:typeCode
entryRelationship:entryRelationship1 |  | 0..* | EntryRelationship | entryRelationship
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources
referenceRange |  | 0..* | InfrastructureRoot |
observationRange |  | 1..1 | ObservationRange |
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required)
text |  | 0..1 | ED |
reference |  | 0..1 | TEL |
@value | C | 0..1 | url | 4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
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.interpretationCode | required | ObservationInterpretation
Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: COMP
Observation.referenceRange.observationRange.classCode | required | ActClassObservation

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-16804 | error | Observation.referenceRange.observationRange.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804). : |
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: 2.16.840.1.113883.10.20.22.4.69
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: ObservationType (extensible)
derivationExpr |  | 0..1 | ST |
text |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime |  | 1..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 1..1 |  |
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: ObservationInterpretation (required)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs |
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:observation, value:typeCode
entryRelationship:entryRelationship1 |  | 0..* | EntryRelationship | entryRelationship
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
referenceRange |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipPertains (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required)
@moodCode |  | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT
templateId |  | 0..* | II |
code |  | 0..1 | CD | Binding: v3 Code System ActCode (extensible)
text |  | 0..1 | ED |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@charset |  | 0..1 | cs |
@compression |  | 0..1 | cs | Binding: CompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs |
@representation |  | 0..1 | cs |
data[x] |  | 0..1 |  |
dataString |  |  | string(st) |
dataBase64Binary |  |  | base64Binary(bin) |
reference |  | 0..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | url | 4515-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804).
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..* | cs | Binding: AddressUse (required)
thumbnail |  | 0..1 | ED |
value |  | 0..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.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Observation.interpretationCode | required | ObservationInterpretation
Observation.interpretationCode.nullFlavor | required | NullFlavor
Observation.methodCode | extensible | ObservationMethod
Observation.entryRelationship:entryRelationship1.nullFlavor | required | NullFlavor
Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: COMP
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.code | extensible | ActCode
Observation.referenceRange.observationRange.text.nullFlavor | required | NullFlavor
Observation.referenceRange.observationRange.text.compression | required | CompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm
Observation.referenceRange.observationRange.text.reference.nullFlavor | required | NullFlavor
Observation.referenceRange.observationRange.text.reference.use | required | AddressUse
Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-16804 | error | Observation.referenceRange.observationRange.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-16804). : |
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 (1 nested mandatory element)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

- Assessment Scale Supporting Observation (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleSupportingObservation)

Slices

This structure defines the following Slices:

- The element Observation.templateId is sliced based on the values of value:root, value:extension
- The element Observation.entryRelationship is sliced based on the values of value:observation, value:typeCode

Other representations of profile: CSV, Excel