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: Longitudinal Care Wound Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/LongitudinalCareWoundObservation | Version: 2.1
Draft as of 2023-09-29 | Computable Name: LongitudinalCareWoundObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.114:2015-08-01

This template represents acquired or surgical wounds and is not intended to encompass all wound types. The template applies to wounds such as pressure ulcers, surgical incisions, and deep tissue injury wounds. Information in this template may include information about the wound measurements characteristics.

Usage:

- Use this Logical Model: Health Concern Act, Physical Exam Section 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 ProblemObservation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  |  | ProblemObservation | 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs |
templateId |  | 2..* | II |
templateId:secondary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: ASSERTION
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4
value |  | 1..1 | CD | Binding: Wound Type (preferred)
targetSiteCode |  | 0..1 | CD | Binding: Body Site Value Set (preferred)
qualifier |  | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
name |  | 1..1 | CV |
code |  | 1..1 | cs | Required Pattern: 272741003
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96
value |  | 1..1 | CD |
code |  | 1..1 | cs | Binding: TargetSite Qualifiers (preferred)
author |  | 0..* | AuthorParticipation | Base for all types and resources
entryRelationship |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
entryRelationship:woundMeasurementObservation |  | 0..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | WoundMeasurementObservation | Base for all types and resources
entryRelationship:woundCharacteristic |  | 0..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | WoundCharacteristic | Base for all types and resources
entryRelationship:numberofPressureUlcersObservation |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | NumberofPressureUlcersObservation | Base for all types and resources
entryRelationship:highestPressureUlcerStage |  | 0..1 | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | HighestPressureUlcerStage | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Observation.value | preferred | Wound Type
Observation.targetSiteCode | preferred | Body Site Value Set
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | ProblemObservation | 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, 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:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
templateId:secondary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred)
@code |  | 1..1 | cs | Required Pattern: ASSERTION
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
low |  | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
value |  | 1..1 | CD | Binding: Wound Type (preferred)
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code
translation:alt |  | 0..* | CD |
targetSiteCode |  | 0..1 | CD | Binding: Body Site Value Set (preferred)
qualifier |  | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
name |  | 1..1 | CV |
@code |  | 1..1 | cs | Required Pattern: 272741003
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96
value |  | 1..1 | CD |
@code |  | 1..1 | cs | Binding: TargetSite Qualifiers (preferred)
author |  | 0..* | AuthorParticipation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation
entryRelationship:age |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
observation |  | 1..1 | AgeObservation | Base for all types and resources
entryRelationship:prognosis |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
observation |  | 1..1 | PrognosisObservation | Base for all types and resources
entryRelationship:priority |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
observation |  | 1..1 | PriorityPreference | Base for all types and resources
entryRelationship:status |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
observation |  | 1..1 | ProblemStatus | Base for all types and resources
entryRelationship:woundMeasurementObservation |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | WoundMeasurementObservation | Base for all types and resources
entryRelationship:woundCharacteristic |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | WoundCharacteristic | Base for all types and resources
entryRelationship:numberofPressureUlcersObservation |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | NumberofPressureUlcersObservation | Base for all types and resources
entryRelationship:highestPressureUlcerStage |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | HighestPressureUlcerStage | 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 | Problem Type (SNOMEDCT)
Observation.statusCode | required | ActStatus
Observation.value | preferred | Wound Type
Observation.targetSiteCode | preferred | Body Site Value Set
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : |
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 | ProblemObservation | 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, 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 | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
templateId:secondary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: ASSERTION
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4
@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 | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
@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 | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 1..1 | CD | Binding: Wound Type (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
@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 | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML.
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code
translation:alt |  | 0..* | CD |
@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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..1 | CD | Binding: Body Site Value Set (preferred)
@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 |
qualifier |  | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@inverted |  | 0..1 | bn |
name |  | 1..1 | CV |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 272741003
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96
@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 |
value |  | 1..1 | CD |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: TargetSite Qualifiers (preferred)
@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 |
translation |  | 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 |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation
entryRelationship:age |  | 0..1 | 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: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
@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 | AgeObservation | 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:prognosis |  | 0..1 | 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: REFR
@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 | PrognosisObservation | 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:priority |  | 0..* | 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: REFR
@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 | PriorityPreference | 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:status |  | 0..1 | 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: REFR
@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 | ProblemStatus | 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:woundMeasurementObservation |  | 0..* | 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 | WoundMeasurementObservation | 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:woundCharacteristic |  | 0..* | 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 | WoundCharacteristic | 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:numberofPressureUlcersObservation |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
@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 | NumberofPressureUlcersObservation | 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:highestPressureUlcerStage |  | 0..1 | 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 | HighestPressureUlcerStage | 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 |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Fixed Value: OBS
Observation.templateId:primary.nullFlavor | required | NullFlavor
Observation.templateId:secondary.nullFlavor | required | NullFlavor
Observation.code | preferred | Problem Type (SNOMEDCT)
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 | preferred | Wound Type
Observation.value.nullFlavor | required | NullFlavor
Observation.value.translation:alt.nullFlavor | required | NullFlavor
Observation.interpretationCode | required | ObservationInterpretation
Observation.methodCode | extensible | ObservationMethod
Observation.targetSiteCode | preferred | Body Site Value Set
Observation.targetSiteCode.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.name.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.value.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers
Observation.entryRelationship:age.nullFlavor | required | NullFlavor
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ
Observation.entryRelationship:prognosis.nullFlavor | required | NullFlavor
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:priority.nullFlavor | required | NullFlavor
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:status.nullFlavor | required | NullFlavor
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.nullFlavor | required | NullFlavor
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:woundCharacteristic.nullFlavor | required | NullFlavor
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.nullFlavor | required | NullFlavor
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.nullFlavor | required | NullFlavor
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP
Observation.referenceRange.nullFlavor | required | NullFlavor
Observation.referenceRange.typeCode | required | Fixed Value: REFV

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : |
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 ProblemObservation

Summary

Mandatory: 5 elements (9 nested mandatory elements)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

- Wound Measurement Observation (http://hl7.org/cda/us/ccda/StructureDefinition/WoundMeasurementObservation)
- Wound Characteristic (http://hl7.org/cda/us/ccda/StructureDefinition/WoundCharacteristic)
- Number of Pressure Ulcers Observation (http://hl7.org/cda/us/ccda/StructureDefinition/NumberofPressureUlcersObservation)
- Highest Pressure Ulcer Stage (http://hl7.org/cda/us/ccda/StructureDefinition/HighestPressureUlcerStage)

Differential View

This structure is derived from ProblemObservation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  |  | ProblemObservation | 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship, entryRelationship, entryRelationship
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs |
templateId |  | 2..* | II |
templateId:secondary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CD |
code |  | 1..1 | cs | Required Pattern: ASSERTION
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4
value |  | 1..1 | CD | Binding: Wound Type (preferred)
targetSiteCode |  | 0..1 | CD | Binding: Body Site Value Set (preferred)
qualifier |  | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
name |  | 1..1 | CV |
code |  | 1..1 | cs | Required Pattern: 272741003
codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96
value |  | 1..1 | CD |
code |  | 1..1 | cs | Binding: TargetSite Qualifiers (preferred)
author |  | 0..* | AuthorParticipation | Base for all types and resources
entryRelationship |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
entryRelationship:woundMeasurementObservation |  | 0..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | WoundMeasurementObservation | Base for all types and resources
entryRelationship:woundCharacteristic |  | 0..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | WoundCharacteristic | Base for all types and resources
entryRelationship:numberofPressureUlcersObservation |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | NumberofPressureUlcersObservation | Base for all types and resources
entryRelationship:highestPressureUlcerStage |  | 0..1 | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: COMP
observation |  | 1..1 | HighestPressureUlcerStage | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Observation.value | preferred | Wound Type
Observation.targetSiteCode | preferred | Body Site Value Set
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | ProblemObservation | 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, 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:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
templateId:secondary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred)
@code |  | 1..1 | cs | Required Pattern: ASSERTION
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
low |  | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
value |  | 1..1 | CD | Binding: Wound Type (preferred)
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code
translation:alt |  | 0..* | CD |
targetSiteCode |  | 0..1 | CD | Binding: Body Site Value Set (preferred)
qualifier |  | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
name |  | 1..1 | CV |
@code |  | 1..1 | cs | Required Pattern: 272741003
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96
value |  | 1..1 | CD |
@code |  | 1..1 | cs | Binding: TargetSite Qualifiers (preferred)
author |  | 0..* | AuthorParticipation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation
entryRelationship:age |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
observation |  | 1..1 | AgeObservation | Base for all types and resources
entryRelationship:prognosis |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
observation |  | 1..1 | PrognosisObservation | Base for all types and resources
entryRelationship:priority |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
observation |  | 1..1 | PriorityPreference | Base for all types and resources
entryRelationship:status |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
observation |  | 1..1 | ProblemStatus | Base for all types and resources
entryRelationship:woundMeasurementObservation |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | WoundMeasurementObservation | Base for all types and resources
entryRelationship:woundCharacteristic |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | WoundCharacteristic | Base for all types and resources
entryRelationship:numberofPressureUlcersObservation |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | NumberofPressureUlcersObservation | Base for all types and resources
entryRelationship:highestPressureUlcerStage |  | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP
observation |  | 1..1 | HighestPressureUlcerStage | 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 | Problem Type (SNOMEDCT)
Observation.statusCode | required | ActStatus
Observation.value | preferred | Wound Type
Observation.targetSiteCode | preferred | Body Site Value Set
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : |
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 | ProblemObservation | 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, negationInd, templateId, templateId, id, code, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, 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 | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
templateId:secondary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.114
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: ASSERTION
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4
@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 | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
@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 | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 1..1 | CD | Binding: Wound Type (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
@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 | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML.
Slices for translation |  | 0..* | CD | Slice: Unordered, Open by value:code
translation:alt |  | 0..* | CD |
@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 |
qualifier |  | 0..* | CR |
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..1 | CD | Binding: Body Site Value Set (preferred)
@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 |
qualifier |  | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@inverted |  | 0..1 | bn |
name |  | 1..1 | CV |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: 272741003
@codeSystem |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96
@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 |
value |  | 1..1 | CD |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: TargetSite Qualifiers (preferred)
@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 |
translation |  | 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 |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation
entryRelationship:age |  | 0..1 | 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: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
@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 | AgeObservation | 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:prognosis |  | 0..1 | 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: REFR
@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 | PrognosisObservation | 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:priority |  | 0..* | 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: REFR
@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 | PriorityPreference | 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:status |  | 0..1 | 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: REFR
@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 | ProblemStatus | 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:woundMeasurementObservation |  | 0..* | 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 | WoundMeasurementObservation | 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:woundCharacteristic |  | 0..* | 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 | WoundCharacteristic | 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:numberofPressureUlcersObservation |  | 0..* | EntryRelationship | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
@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 | NumberofPressureUlcersObservation | 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:highestPressureUlcerStage |  | 0..1 | 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 | HighestPressureUlcerStage | 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 |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Fixed Value: OBS
Observation.templateId:primary.nullFlavor | required | NullFlavor
Observation.templateId:secondary.nullFlavor | required | NullFlavor
Observation.code | preferred | Problem Type (SNOMEDCT)
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 | preferred | Wound Type
Observation.value.nullFlavor | required | NullFlavor
Observation.value.translation:alt.nullFlavor | required | NullFlavor
Observation.interpretationCode | required | ObservationInterpretation
Observation.methodCode | extensible | ObservationMethod
Observation.targetSiteCode | preferred | Body Site Value Set
Observation.targetSiteCode.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.name.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.value.nullFlavor | required | NullFlavor
Observation.targetSiteCode.qualifier.value.code | preferred | TargetSite Qualifiers
Observation.entryRelationship:age.nullFlavor | required | NullFlavor
Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ
Observation.entryRelationship:prognosis.nullFlavor | required | NullFlavor
Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:priority.nullFlavor | required | NullFlavor
Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:status.nullFlavor | required | NullFlavor
Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR
Observation.entryRelationship:woundMeasurementObservation.nullFlavor | required | NullFlavor
Observation.entryRelationship:woundMeasurementObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:woundCharacteristic.nullFlavor | required | NullFlavor
Observation.entryRelationship:woundCharacteristic.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:numberofPressureUlcersObservation.nullFlavor | required | NullFlavor
Observation.entryRelationship:numberofPressureUlcersObservation.typeCode | required | Fixed Value: COMP
Observation.entryRelationship:highestPressureUlcerStage.nullFlavor | required | NullFlavor
Observation.entryRelationship:highestPressureUlcerStage.typeCode | required | Fixed Value: COMP
Observation.referenceRange.nullFlavor | required | NullFlavor
Observation.referenceRange.typeCode | required | Fixed Value: REFV

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : |
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 ProblemObservation

Summary

Mandatory: 5 elements (9 nested mandatory elements)
Fixed Value: 4 elements

Structures

This structure refers to these other structures:

- Wound Measurement Observation (http://hl7.org/cda/us/ccda/StructureDefinition/WoundMeasurementObservation)
- Wound Characteristic (http://hl7.org/cda/us/ccda/StructureDefinition/WoundCharacteristic)
- Number of Pressure Ulcers Observation (http://hl7.org/cda/us/ccda/StructureDefinition/NumberofPressureUlcersObservation)
- Highest Pressure Ulcer Stage (http://hl7.org/cda/us/ccda/StructureDefinition/HighestPressureUlcerStage)

Other representations of profile: CSV, Excel