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: Social History Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistoryObservation | Version: 2.1
Draft as of 2023-09-29 | Computable Name: SocialHistoryObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2022-06-01

This template represents a patient’s job (occupation and industry), lifestyle, and environmental health risk factors. Demographic data (e.g., marital status, race, ethnicity, religious affiliation) are captured in the header. Though tobacco use and exposure may be represented with a Social History Observation, it is recommended to use the Current Smoking Status template or the Tobacco Use template instead, to represent smoking or tobacco habits. There are supplemental templates and guidance for observations of Occupational Data for Health, nutrition and pregnancy that could be captured in the Social History Observation, and implementers may want to consider using those more specific templates in the Social History section.

Usage:

- Derived from this Logical Model: Basic Industry Observation, Basic Occupation Observation, Gender Identity Observation, Sexual Orientation Observation and Tribal Affiliation Observation
- Use this Logical Model: Health Concern Act, Risk Concern Act and Social History Section

### Formal Views of Profile Content

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

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

This structure is derived from CDAR2.Observation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  |  | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
classCode |  | 1..1 | cs | Fixed Value: OBS
moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId: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
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: 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).
statusCode |  | 1..1 | CS |
code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value | C | 0..1 | ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 4515-8555: 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. 4515-32957: 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).
author |  | 0..* | AuthorParticipation | Base for all types and resources
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 | 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 | Fixed Value: SPRT
act |  | 1..1 | EntryReference | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Observation.code | preferred | Social History Type

#### 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). : |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS
@moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId: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
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: 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).
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value | C | 0..1 |  | 4515-8555: 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. 4515-32957: 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).
value |  |  | ANY |
value |  |  | BL |
value |  |  | ED |
value |  |  | ST |
value |  |  | CD |
value |  |  | CV |
value |  |  | CE |
value |  |  | SC |
value |  |  | II |
value |  |  | TEL |
value |  |  | AD |
value |  |  | EN |
value |  |  | INT |
value |  |  | REAL |
value |  |  | PQ |
value |  |  | MO |
value |  |  | TS |
value |  |  | IVL_PQ |
value |  |  | IVL_TS |
value |  |  | PIVL_TS |
value |  |  | EIVL_TS |
value |  |  | SXPR_TS |
value |  |  | RTO_PQ_PQ |
author |  | 0..* | AuthorParticipation | Base for all types and resources
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.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 | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS
@moodCode |  | 1..1 | cs | Fixed Value: EVN
@negationInd |  | 0..1 | bl |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId: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
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: 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).
derivationExpr |  | 0..1 | ST |
text |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime |  | 1..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value | C | 0..1 |  | 4515-8555: 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. 4515-32957: 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).
value |  |  | ANY |
value |  |  | BL |
value |  |  | ED |
value |  |  | ST |
value |  |  | CD |
value |  |  | CV |
value |  |  | CE |
value |  |  | SC |
value |  |  | II |
value |  |  | TEL |
value |  |  | AD |
value |  |  | EN |
value |  |  | INT |
value |  |  | REAL |
value |  |  | PQ |
value |  |  | MO |
value |  |  | TS |
value |  |  | IVL_PQ |
value |  |  | IVL_TS |
value |  |  | PIVL_TS |
value |  |  | EIVL_TS |
value |  |  | SXPR_TS |
value |  |  | RTO_PQ_PQ |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
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.code | preferred | Social History Type
Observation.statusCode | required | ActStatus
Observation.statusCode.nullFlavor | required | NullFlavor
Observation.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Observation.interpretationCode | required | ObservationInterpretation
Observation.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 CDAR2.Observation

Summary

Mandatory: 9 elements (2 nested mandatory elements)
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

- Author Participation (http://hl7.org/cda/us/ccda/StructureDefinition/AuthorParticipation)
- Assessment Scale Observation (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation)
- Entry Reference (http://hl7.org/cda/us/ccda/StructureDefinition/EntryReference)

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from CDAR2.Observation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  |  | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange
classCode |  | 1..1 | cs | Fixed Value: OBS
moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId: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
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: 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).
statusCode |  | 1..1 | CS |
code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value | C | 0..1 | ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 4515-8555: 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. 4515-32957: 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).
author |  | 0..* | AuthorParticipation | Base for all types and resources
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 | 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 | Fixed Value: SPRT
act |  | 1..1 | EntryReference | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Observation.code | preferred | Social History Type

#### 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). : |

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS
@moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId: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
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: 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).
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime |  | 1..1 | IVL_TS |
value | C | 0..1 |  | 4515-8555: 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. 4515-32957: 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).
value |  |  | ANY |
value |  |  | BL |
value |  |  | ED |
value |  |  | ST |
value |  |  | CD |
value |  |  | CV |
value |  |  | CE |
value |  |  | SC |
value |  |  | II |
value |  |  | TEL |
value |  |  | AD |
value |  |  | EN |
value |  |  | INT |
value |  |  | REAL |
value |  |  | PQ |
value |  |  | MO |
value |  |  | TS |
value |  |  | IVL_PQ |
value |  |  | IVL_TS |
value |  |  | PIVL_TS |
value |  |  | EIVL_TS |
value |  |  | SXPR_TS |
value |  |  | RTO_PQ_PQ |
author |  | 0..* | AuthorParticipation | Base for all types and resources
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.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 | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS
@moodCode |  | 1..1 | cs | Fixed Value: EVN
@negationInd |  | 0..1 | bl |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId: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
id |  | 1..* | II |
code | C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: 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).
derivationExpr |  | 0..1 | ST |
text |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime |  | 1..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value | C | 0..1 |  | 4515-8555: 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. 4515-32957: 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).
value |  |  | ANY |
value |  |  | BL |
value |  |  | ED |
value |  |  | ST |
value |  |  | CD |
value |  |  | CV |
value |  |  | CE |
value |  |  | SC |
value |  |  | II |
value |  |  | TEL |
value |  |  | AD |
value |  |  | EN |
value |  |  | INT |
value |  |  | REAL |
value |  |  | PQ |
value |  |  | MO |
value |  |  | TS |
value |  |  | IVL_PQ |
value |  |  | IVL_TS |
value |  |  | PIVL_TS |
value |  |  | EIVL_TS |
value |  |  | SXPR_TS |
value |  |  | RTO_PQ_PQ |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
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.code | preferred | Social History Type
Observation.statusCode | required | ActStatus
Observation.statusCode.nullFlavor | required | NullFlavor
Observation.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Observation.interpretationCode | required | ObservationInterpretation
Observation.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 CDAR2.Observation

Summary

Mandatory: 9 elements (2 nested mandatory elements)
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

- Author Participation (http://hl7.org/cda/us/ccda/StructureDefinition/AuthorParticipation)
- Assessment Scale Observation (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation)
- Entry Reference (http://hl7.org/cda/us/ccda/StructureDefinition/EntryReference)

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel