Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions
Active as of 2022-05-13 |
Definitions for the 2.16.840.1.113883.10.20.15.3.8 resource profile.
1. Observation | |
Control | 1..1 |
2. Observation.classCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ActClassObservation |
Type | code |
Requirements | SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-451). |
Pattern Value | OBS |
3. Observation.moodCode | |
Control | 1..1 |
Type | code |
Requirements | SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-452). |
Pattern Value | EVN |
4. Observation.negationInd | |
Control | 0..1 |
Type | boolean |
5. Observation.realmCode | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CS |
6. Observation.typeId | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/II |
7. Observation.templateId | |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/II |
Slicing | This element introduces a set of slices on Observation.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
8. Observation.templateId:primary | |
SliceName | primary |
Definition | When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/II |
Requirements | SHALL contain exactly one [1..1] templateId (CONF:81-16768) such that it |
9. Observation.templateId:primary.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from NullFlavor |
Type | code |
10. Observation.templateId:primary.assigningAuthorityName | |
Definition | A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form. |
Control | 0..1 |
Type | string |
11. Observation.templateId:primary.displayable | |
Definition | Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false). |
Control | 0..1 |
Type | boolean |
12. Observation.templateId:primary.root | |
Definition | A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. |
Control | 1..1 |
Type | string |
Requirements | SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.8" (CONF:81-16868). |
Pattern Value | 2.16.840.1.113883.10.20.15.3.8 |
13. Observation.templateId:primary.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 0..1 |
Type | string |
14. Observation.id | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/II |
15. Observation.code | |
Control | 1..1 |
Binding | The codes SHALL be taken from ObservationType; other codes may be used where these codes are not suitable |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
Requirements | SHALL contain exactly one [1..1] code (CONF:81-19153). |
16. Observation.code.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from NullFlavor |
Type | code |
17. Observation.code.code | |
Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
Control | 1..1 |
Type | string |
Requirements | This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:81-19154). |
Pattern Value | ASSERTION |
18. Observation.code.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 1..1 |
Type | string |
Requirements | This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: HL7ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:81-26505). |
Pattern Value | 2.16.840.1.113883.5.4 |
19. Observation.code.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..1 |
Type | string |
20. Observation.code.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..1 |
Type | string |
21. Observation.code.displayName | |
Definition | A name or title for the code, under which the sending system shows the code value to its users. |
Control | 0..1 |
Type | string |
22. Observation.code.sdtcValueSet | |
Definition | The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string |
23. Observation.code.sdtcValueSetVersion | |
Definition | The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string |
24. Observation.code.originalText | |
Definition | The text or phrase used as the basis for the coding. |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
25. Observation.code.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CR |
26. Observation.code.translation | |
Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
27. Observation.derivationExpr | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ST |
28. Observation.text | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
29. Observation.statusCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ActStatus |
Type | http://hl7.org/fhir/cda/StructureDefinition/CS |
Requirements | SHALL contain exactly one [1..1] statusCode (CONF:81-455). |
30. Observation.statusCode.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from NullFlavor |
Type | code |
31. Observation.statusCode.code | |
Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
Control | 1..1 |
Type | string |
Requirements | This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:81-19110). |
Pattern Value | completed |
32. Observation.statusCode.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 0..0 |
Type | string |
33. Observation.statusCode.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..0 |
Type | string |
34. Observation.statusCode.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..0 |
Type | string |
35. Observation.statusCode.displayName | |
Definition | A name or title for the code, under which the sending system shows the code value to its users. |
Control | 0..0 |
Type | string |
36. Observation.statusCode.sdtcValueSet | |
Definition | The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string |
37. Observation.statusCode.sdtcValueSetVersion | |
Definition | The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string |
38. Observation.statusCode.originalText | |
Definition | The text or phrase used as the basis for the coding. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
39. Observation.statusCode.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/CR |
40. Observation.statusCode.translation | |
Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
41. Observation.effectiveTime | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/IVL-TS |
Requirements | SHOULD contain zero or one [0..1] effectiveTime (CONF:81-2018). |
42. Observation.priorityCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from ActPriority; other codes may be used where these codes are not suitable |
Type | http://hl7.org/fhir/cda/StructureDefinition/CE |
43. Observation.repeatNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/IVL-INT |
44. Observation.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from HumanLanguage |
Type | http://hl7.org/fhir/cda/StructureDefinition/CS |
45. Observation.value | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
Requirements | SHALL contain exactly one [1..1] value with @xsi:type="CD". |
Comments | 201707 Errata Comment 1599: Added value set "Pregnancy Status" urn:oid:2.16.840.1.113883.11.20.9.85 to Trifolia. Contains values (all from SNOMED): Pregnant (finding), Possible Pregnancy (finding), Not Pregnant (finding). Updated Pregnancy Observation template - removed binding to single code (Pregnant) and added SHALL DYNAMIC binding to above value set. |
46. Observation.value.nullFlavor | |
Definition | If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing. |
Control | 0..1 |
Binding | The codes SHALL be taken from NullFlavor |
Type | code |
47. Observation.value.code | |
Definition | The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache. |
Control | 1..1 |
Binding | The codes SHALL be taken from Extended Pregnancy Status |
Type | string |
Requirements | This code SHALL be selected from ValueSet Extended Pregnancy Status urn:oid:2.16.840.1.113762.1.4.1099.24 DYNAMIC (CONF:81-457). |
48. Observation.value.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 0..1 |
Type | string |
49. Observation.value.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..1 |
Type | string |
50. Observation.value.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..1 |
Type | string |
51. Observation.value.displayName | |
Definition | A name or title for the code, under which the sending system shows the code value to its users. |
Control | 0..1 |
Type | string |
52. Observation.value.sdtcValueSet | |
Definition | The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string |
53. Observation.value.sdtcValueSetVersion | |
Definition | The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept. |
Control | 0..1 |
Type | string |
54. Observation.value.originalText | |
Definition | The text or phrase used as the basis for the coding. |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
55. Observation.value.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CR |
56. Observation.value.translation | |
Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
57. Observation.interpretationCode | |
Control | 0..* |
Binding | The codes SHALL be taken from ObservationInterpretation |
Type | http://hl7.org/fhir/cda/StructureDefinition/CE |
58. Observation.methodCode | |
Control | 0..* |
Binding | The codes SHALL be taken from ObservationMethod; other codes may be used where these codes are not suitable |
Type | http://hl7.org/fhir/cda/StructureDefinition/CE |
59. Observation.targetSiteCode | |
Definition | Drawn from concept domain ActSite |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
60. Observation.subject | |
Control | 0..1 |
Type | Element |
61. Observation.subject.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ParticipationTargetSubject |
Type | code |
Default Value | SBJ |
Fixed Value | SBJ |
62. Observation.subject.contextControlCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ContextControl |
Type | code |
Default Value | OP |
Fixed Value | OP |
63. Observation.subject.awarenessCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable |
Type | http://hl7.org/fhir/cda/StructureDefinition/CE |
64. Observation.subject.relatedSubject | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RelatedSubject |
65. Observation.specimen | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Specimen |
66. Observation.performer | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Performer2 |
67. Observation.author | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Author |
68. Observation.informant | |
Control | 0..* |
Type | Element |
69. Observation.informant.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ParticipationInformationGenerator |
Type | code |
Default Value | INF |
Fixed Value | INF |
70. Observation.informant.contextControlCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ContextControl |
Type | code |
Default Value | OP |
Fixed Value | OP |
71. Observation.informant.assignedEntity | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/AssignedEntity |
72. Observation.informant.relatedEntity | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RelatedEntity |
73. Observation.participant | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Participant2 |
74. Observation.entryRelationship | |
Control | 0..* |
Type | Element |
Invariants | Defined on this element obs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act (: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1) |
Slicing | This element introduces a set of slices on Observation.entryRelationship. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
75. Observation.entryRelationship.typeCode | |
Control | 1..1 |
Type | code |
76. Observation.entryRelationship.inversionInd | |
Control | 0..1 |
Type | boolean |
77. Observation.entryRelationship.contextConductionInd | |
Control | 1..1 |
Type | boolean |
Default Value | true |
78. Observation.entryRelationship.sequenceNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/INT |
79. Observation.entryRelationship.negationInd | |
Control | 0..1 |
Type | boolean |
80. Observation.entryRelationship.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
81. Observation.entryRelationship.observation | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Observation |
82. Observation.entryRelationship.regionOfInterest | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest |
83. Observation.entryRelationship.observationMedia | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationMedia |
84. Observation.entryRelationship.substanceAdministration | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration |
85. Observation.entryRelationship.supply | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Supply |
86. Observation.entryRelationship.procedure | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Procedure |
87. Observation.entryRelationship.encounter | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Encounter |
88. Observation.entryRelationship.organizer | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Organizer |
89. Observation.entryRelationship.act | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Act |
90. Observation.entryRelationship:estimatedDateofDelivery | |
SliceName | estimatedDateofDelivery |
Control | 0..1 |
Type | Element |
Requirements | MAY contain zero or one [0..1] entryRelationship (CONF:81-458) such that it |
Invariants | Defined on this element obs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act (: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1) |
91. Observation.entryRelationship:estimatedDateofDelivery.typeCode | |
Control | 1..1 |
Type | code |
Requirements | SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:81-459). |
Pattern Value | REFR |
92. Observation.entryRelationship:estimatedDateofDelivery.inversionInd | |
Control | 0..1 |
Type | boolean |
93. Observation.entryRelationship:estimatedDateofDelivery.contextConductionInd | |
Control | 1..1 |
Type | boolean |
Default Value | true |
94. Observation.entryRelationship:estimatedDateofDelivery.sequenceNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/INT |
95. Observation.entryRelationship:estimatedDateofDelivery.negationInd | |
Control | 0..1 |
Type | boolean |
96. Observation.entryRelationship:estimatedDateofDelivery.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
97. Observation.entryRelationship:estimatedDateofDelivery.observation | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Observation(EstimatedDateofDelivery) |
Requirements | SHALL contain exactly one [1..1] observationEstimated Date of Delivery (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.1) (CONF:81-15584). |
98. Observation.entryRelationship:estimatedDateofDelivery.regionOfInterest | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest |
99. Observation.entryRelationship:estimatedDateofDelivery.observationMedia | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationMedia |
100. Observation.entryRelationship:estimatedDateofDelivery.substanceAdministration | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration |
101. Observation.entryRelationship:estimatedDateofDelivery.supply | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Supply |
102. Observation.entryRelationship:estimatedDateofDelivery.procedure | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Procedure |
103. Observation.entryRelationship:estimatedDateofDelivery.encounter | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Encounter |
104. Observation.entryRelationship:estimatedDateofDelivery.organizer | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Organizer |
105. Observation.entryRelationship:estimatedDateofDelivery.act | |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Act |
106. Observation.reference | |
Control | 0..* |
Type | Element |
107. Observation.reference.typeCode | |
Control | 1..1 |
Type | code |
108. Observation.reference.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
109. Observation.reference.externalAct | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalAct |
110. Observation.reference.externalObservation | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalObservation |
111. Observation.reference.externalProcedure | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure |
112. Observation.reference.externalDocument | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalDocument |
113. Observation.precondition | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Precondition |
114. Observation.referenceRange | |
Control | 0..* |
Type | Element |
115. Observation.referenceRange.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ActRelationshipPertains |
Type | code |
Default Value | REFV |
Fixed Value | REFV |
116. Observation.referenceRange.observationRange | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationRange |