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: Gender Identity Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/GenderIdentityObservation | Version: 2.1
Draft as of 2023-09-29 | Computable Name: GenderIdentityObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.34.3.45:2023-05-01

This observation represents the gender identity of the patient, defined as:

> “Ones basic sense of being male, female, or other gender (for example, transgender or gender queer). Gender identity can be congruent or incongruent with ones sex assigned at birth based on the appearance of external genitalia. (Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) CommunityA Field Guide, The Joint Commission (2011).)

This template follows the guidelines from the HL7 Gender Harmony project. This template is based on C-CDA Social History Observation template.

This observation is not appropriate for recording patient gender (administrativeGender) or birth sex.

Usage:

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

### Formal Views of Profile Content

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

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

This structure is derived from SocialHistoryObservation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | SocialHistoryObservation | 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, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs |
templateId |  | 2..* | II |
templateId:templateId1 |  | 1..1 | II | templateId
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.34.3.45
extension |  | 1..1 | st | Required Pattern: 2023-05-01
code |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: 76691-5
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
statusCode |  | 1..1 | CS |
code |  | 1..1 | cs |
effectiveTime |  | 1..1 | IVL_TS |
low |  | 1..1 | IVXB_TS |
high |  | 0..1 | IVXB_TS |
value |  | 1..1 | CD | Binding: Gender Identity USCDI core (required)
nullFlavor |  | 0..1 | cs | Binding: Asked but Unknown and Other (preferred)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Observation.value | required | Gender Identity USCDI core
Observation.value.nullFlavor | preferred | Asked but Unknown and Other

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | SocialHistoryObservation | 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, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship 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 |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:social-history-obs |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
templateId:templateId1 |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.34.3.45
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred)
@code |  | 1..1 | cs | Required Pattern: 76691-5
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
low |  | 1..1 | IVXB_TS |
high |  | 0..1 | IVXB_TS |
value | C | 1..1 | CD | Binding: Gender Identity USCDI core (required)
@nullFlavor |  | 0..1 | cs | Binding: Asked but Unknown and Other (preferred)
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by value:act, value:observation, value:typeCode
entryRelationship:social-history-entry-sprt-obs |  | 0..* | EntryRelationship | entryRelationship
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT
observation |  | 1..1 | AssessmentScaleObservation | Base for all types and resources
entryRelationship:social-history-entry-sprt-act |  | 0..* | EntryRelationship | entryRelationship
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT
act |  | 1..1 | EntryReference | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Fixed Value: OBS
Observation.code | preferred | Social History Type
Observation.statusCode | required | ActStatus
Observation.value | required | Gender Identity USCDI core
Observation.value.nullFlavor | preferred | Asked but Unknown and Other
Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-8555 | error | 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. : |
4515-32956 | error | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : |
4515-32957 | error | Observation.value | If the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957). : |
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 | SocialHistoryObservation | 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, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship 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 |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:social-history-obs |  | 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: 2.16.840.1.113883.10.20.22.4.38
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
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: 2.16.840.1.113883.10.20.34.3.45
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 76691-5
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
@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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
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 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value | C | 1..1 | CD | Binding: Gender Identity USCDI core (required)
@nullFlavor |  | 0..1 | cs | Binding: Asked but Unknown and Other (preferred)
@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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | AuthorParticipation | Base for all types and resources
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by value:act, value:observation, value:typeCode
entryRelationship:social-history-entry-sprt-obs |  | 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: SPRT
@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 | AssessmentScaleObservation | 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 |
entryRelationship:social-history-entry-sprt-act |  | 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: SPRT
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 1..1 | EntryReference | Base for all types and resources
encounter |  | 0..1 | Encounter |
observation |  | 0..1 | Observation |
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 |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Fixed Value: OBS
Observation.templateId:social-history-obs.nullFlavor | required | NullFlavor
Observation.templateId:templateId1.nullFlavor | required | NullFlavor
Observation.code | preferred | Social History Type
Observation.code.nullFlavor | required | NullFlavor
Observation.statusCode | required | ActStatus
Observation.statusCode.nullFlavor | required | NullFlavor
Observation.effectiveTime.nullFlavor | required | NullFlavor
Observation.effectiveTime.operator | required | SetOperator
Observation.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Observation.value | required | Gender Identity USCDI core
Observation.value.nullFlavor | preferred | Asked but Unknown and Other
Observation.interpretationCode | required | ObservationInterpretation
Observation.methodCode | extensible | ObservationMethod
Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavor | required | NullFlavor
Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.nullFlavor | required | NullFlavor
Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT
Observation.referenceRange.nullFlavor | required | NullFlavor
Observation.referenceRange.typeCode | required | Fixed Value: REFV

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-8555 | error | 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. : |
4515-32956 | error | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : |
4515-32957 | error | Observation.value | If the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957). : |
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 SocialHistoryObservation

Summary

Mandatory: 7 elements

Differential View

This structure is derived from SocialHistoryObservation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | SocialHistoryObservation | 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, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs |
templateId |  | 2..* | II |
templateId:templateId1 |  | 1..1 | II | templateId
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.34.3.45
extension |  | 1..1 | st | Required Pattern: 2023-05-01
code |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: 76691-5
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
statusCode |  | 1..1 | CS |
code |  | 1..1 | cs |
effectiveTime |  | 1..1 | IVL_TS |
low |  | 1..1 | IVXB_TS |
high |  | 0..1 | IVXB_TS |
value |  | 1..1 | CD | Binding: Gender Identity USCDI core (required)
nullFlavor |  | 0..1 | cs | Binding: Asked but Unknown and Other (preferred)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Observation.value | required | Gender Identity USCDI core
Observation.value.nullFlavor | preferred | Asked but Unknown and Other

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | SocialHistoryObservation | 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, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship 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 |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:social-history-obs |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
templateId:templateId1 |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.34.3.45
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred)
@code |  | 1..1 | cs | Required Pattern: 76691-5
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
low |  | 1..1 | IVXB_TS |
high |  | 0..1 | IVXB_TS |
value | C | 1..1 | CD | Binding: Gender Identity USCDI core (required)
@nullFlavor |  | 0..1 | cs | Binding: Asked but Unknown and Other (preferred)
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by value:act, value:observation, value:typeCode
entryRelationship:social-history-entry-sprt-obs |  | 0..* | EntryRelationship | entryRelationship
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT
observation |  | 1..1 | AssessmentScaleObservation | Base for all types and resources
entryRelationship:social-history-entry-sprt-act |  | 0..* | EntryRelationship | entryRelationship
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT
act |  | 1..1 | EntryReference | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Fixed Value: OBS
Observation.code | preferred | Social History Type
Observation.statusCode | required | ActStatus
Observation.value | required | Gender Identity USCDI core
Observation.value.nullFlavor | preferred | Asked but Unknown and Other
Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-8555 | error | 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. : |
4515-32956 | error | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : |
4515-32957 | error | Observation.value | If the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957). : |
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 | SocialHistoryObservation | 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, moodCode, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship 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 |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:social-history-obs |  | 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: 2.16.840.1.113883.10.20.22.4.38
@extension |  | 1..1 | st | Required Pattern: 2022-06-01
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: 2.16.840.1.113883.10.20.34.3.45
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 76691-5
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1
@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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
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 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value | C | 1..1 | CD | Binding: Gender Identity USCDI core (required)
@nullFlavor |  | 0..1 | cs | Binding: Asked but Unknown and Other (preferred)
@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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | AuthorParticipation | Base for all types and resources
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship |  | 1..* | EntryRelationship | Slice: Unordered, Open by value:act, value:observation, value:typeCode
entryRelationship:social-history-entry-sprt-obs |  | 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: SPRT
@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 | AssessmentScaleObservation | 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 |
entryRelationship:social-history-entry-sprt-act |  | 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: SPRT
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 1..1 | EntryReference | Base for all types and resources
encounter |  | 0..1 | Encounter |
observation |  | 0..1 | Observation |
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 |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Fixed Value: OBS
Observation.templateId:social-history-obs.nullFlavor | required | NullFlavor
Observation.templateId:templateId1.nullFlavor | required | NullFlavor
Observation.code | preferred | Social History Type
Observation.code.nullFlavor | required | NullFlavor
Observation.statusCode | required | ActStatus
Observation.statusCode.nullFlavor | required | NullFlavor
Observation.effectiveTime.nullFlavor | required | NullFlavor
Observation.effectiveTime.operator | required | SetOperator
Observation.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Observation.value | required | Gender Identity USCDI core
Observation.value.nullFlavor | preferred | Asked but Unknown and Other
Observation.interpretationCode | required | ObservationInterpretation
Observation.methodCode | extensible | ObservationMethod
Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavor | required | NullFlavor
Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT
Observation.entryRelationship:social-history-entry-sprt-act.nullFlavor | required | NullFlavor
Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT
Observation.referenceRange.nullFlavor | required | NullFlavor
Observation.referenceRange.typeCode | required | Fixed Value: REFV

#### Constraints

Id | Grade | Path(s) | Details | Requirements
4515-8555 | error | 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. : |
4515-32956 | error | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : |
4515-32957 | error | Observation.value | If the Social History Observation is a Social Determinant of Health Observation, the observation/value code **SHOULD** be selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32957). : |
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 SocialHistoryObservation

Summary

Mandatory: 7 elements

Other representations of profile: CSV, Excel