Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

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

Resource Profile: ResultObservation - Detailed Descriptions

Active as of 2022-05-13

Definitions for the 2.16.840.1.113883.10.20.22.4.2 resource profile.

1. Observation
Control1..1
2. Observation.classCode
Control1..1
BindingThe codes SHALL be taken from ActClassObservation
Typecode
Requirements

SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-7130).

Pattern ValueOBS
3. Observation.moodCode
Control1..1
Typecode
Requirements

SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-7131).

Pattern ValueEVN
4. Observation.negationInd
Control0..1
Typeboolean
5. Observation.realmCode
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
6. Observation.typeId
Control0..1
Typehttp://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

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
SlicingThis element introduces a set of slices on Observation.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ extension
  • ,
  • value @ root
8. Observation.templateId:primary
SliceNameprimary
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

Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain exactly one [1..1] templateId (CONF:1198-7136) 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.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
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.

Control0..1
Typestring
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).

Control0..1
Typeboolean
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.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2" (CONF:1198-9138).

Pattern Value2.16.840.1.113883.10.20.22.4.2
13. Observation.templateId:primary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32575).

Pattern Value2015-08-01
14. Observation.id
Control1..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain at least one [1..*] id (CONF:1198-7137).

15. Observation.code
Control1..1
BindingThe codes SHALL be taken from ObservationType; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133).

InvariantsDefined on this element
1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). (: )
16. Observation.derivationExpr
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ST
17. Observation.text
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
18. Observation.statusCode
Control1..1
BindingThe codes SHALL be taken from ActStatus
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
Requirements

SHALL contain exactly one [1..1] statusCode (CONF:1198-7134).

19. Observation.statusCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
20. 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.

Control1..1
BindingThe codes SHALL be taken from Result Status
Typestring
Requirements

This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC (CONF:1198-14849).

21. Observation.statusCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring
22. Observation.statusCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring
23. Observation.statusCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring
24. Observation.statusCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring
25. 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.

Control0..1
Typestring
26. 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.

Control0..1
Typestring
27. Observation.statusCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
28. Observation.statusCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
29. Observation.statusCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
30. Observation.effectiveTime
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS
Requirements

SHALL contain exactly one [1..1] effectiveTime (CONF:1198-7140).

31. Observation.priorityCode
Control0..1
BindingThe codes SHALL be taken from ActPriority; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
32. Observation.repeatNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-INT
33. Observation.languageCode
Control0..1
BindingThe codes SHALL be taken from HumanLanguage
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
34. Observation.value
Control1..1
TypeChoice of: http://hl7.org/fhir/cda/StructureDefinition/BL, http://hl7.org/fhir/cda/StructureDefinition/ED, http://hl7.org/fhir/cda/StructureDefinition/ST, http://hl7.org/fhir/cda/StructureDefinition/CD, http://hl7.org/fhir/cda/StructureDefinition/CV, http://hl7.org/fhir/cda/StructureDefinition/CE, http://hl7.org/fhir/cda/StructureDefinition/SC, http://hl7.org/fhir/cda/StructureDefinition/II, http://hl7.org/fhir/cda/StructureDefinition/TEL, http://hl7.org/fhir/cda/StructureDefinition/AD, http://hl7.org/fhir/cda/StructureDefinition/EN, http://hl7.org/fhir/cda/StructureDefinition/INT, http://hl7.org/fhir/cda/StructureDefinition/REAL, http://hl7.org/fhir/cda/StructureDefinition/PQ, http://hl7.org/fhir/cda/StructureDefinition/MO, http://hl7.org/fhir/cda/StructureDefinition/TS, http://hl7.org/fhir/cda/StructureDefinition/IVL-PQ, http://hl7.org/fhir/cda/StructureDefinition/IVL-TS, http://hl7.org/fhir/cda/StructureDefinition/PIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/EIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/SXPR-TS, http://hl7.org/fhir/cda/StructureDefinition/RTO-PQ-PQ
Requirements

SHALL contain exactly one [1..1] value (CONF:1198-7143).

InvariantsDefined on this element
1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). (: )
1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). (: )
1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). (: )
35. Observation.interpretationCode
Control0..*
BindingThe codes SHALL be taken from ObservationInterpretation
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
Requirements

SHOULD contain zero or more [0..*] interpretationCode (CONF:1198-7147).

36. Observation.interpretationCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
37. Observation.interpretationCode.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.

Control1..1
BindingThe codes SHALL be taken from Observation Interpretation (HL7)
Typestring
Requirements

The interpretationCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 DYNAMIC (CONF:1198-32476).

38. Observation.interpretationCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring
39. Observation.interpretationCode.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring
40. Observation.interpretationCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring
41. Observation.interpretationCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring
42. Observation.interpretationCode.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring
43. Observation.interpretationCode.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.

Control0..1
Typestring
44. Observation.interpretationCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
45. Observation.interpretationCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
46. Observation.interpretationCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
47. Observation.methodCode
Control0..1
BindingThe codes SHALL be taken from ObservationMethod; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
Requirements

MAY contain zero or one [0..1] methodCode (CONF:1198-7148).

48. Observation.targetSiteCode
Definition

Drawn from concept domain ActSite

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

MAY contain zero or one [0..1] targetSiteCode (CONF:1198-7153).

49. Observation.subject
Control0..1
TypeElement
50. Observation.subject.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetSubject
Typecode
Default ValueSBJ
Fixed ValueSBJ
51. Observation.subject.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
52. Observation.subject.awarenessCode
Control0..1
BindingThe codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
53. Observation.subject.relatedSubject
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
54. Observation.specimen
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Specimen
55. Observation.performer
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Performer2
56. Observation.author
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Author(AuthorParticipation)
Requirements

SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-7149).

57. Observation.informant
Control0..*
TypeElement
58. Observation.informant.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationInformationGenerator
Typecode
Default ValueINF
Fixed ValueINF
59. Observation.informant.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
60. Observation.informant.assignedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
61. Observation.informant.relatedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
62. Observation.participant
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Participant2
63. Observation.entryRelationship
Control0..*
TypeElement
InvariantsDefined 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)
64. Observation.entryRelationship.typeCode
Control1..1
Typecode
65. Observation.entryRelationship.inversionInd
Control0..1
Typeboolean
66. Observation.entryRelationship.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
67. Observation.entryRelationship.sequenceNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/INT
68. Observation.entryRelationship.negationInd
Control0..1
Typeboolean
69. Observation.entryRelationship.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
70. Observation.entryRelationship.observation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
71. Observation.entryRelationship.regionOfInterest
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
72. Observation.entryRelationship.observationMedia
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
73. Observation.entryRelationship.substanceAdministration
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
74. Observation.entryRelationship.supply
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
75. Observation.entryRelationship.procedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
76. Observation.entryRelationship.encounter
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
77. Observation.entryRelationship.organizer
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
78. Observation.entryRelationship.act
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
79. Observation.reference
Control0..*
TypeElement
80. Observation.reference.typeCode
Control1..1
Typecode
81. Observation.reference.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
82. Observation.reference.externalAct
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalAct
83. Observation.reference.externalObservation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalObservation
84. Observation.reference.externalProcedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure
85. Observation.reference.externalDocument
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalDocument
86. Observation.precondition
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Precondition
87. Observation.referenceRange
Control0..*
TypeElement
Requirements

SHOULD contain zero or more [0..*] referenceRange (CONF:1198-7150).

88. Observation.referenceRange.typeCode
Control1..1
BindingThe codes SHALL be taken from ActRelationshipPertains
Typecode
Default ValueREFV
Fixed ValueREFV
89. Observation.referenceRange.observationRange
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationRange
Requirements

The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:1198-7151).

90. Observation.referenceRange.observationRange.classCode
Control1..1
BindingThe codes SHALL be taken from ActClassObservation
Typecode
Default ValueOBS
91. Observation.referenceRange.observationRange.moodCode
Control1..1
BindingThe codes SHALL be taken from ActMoodPredicate
Typecode
Default ValueEVN.CRT
Fixed ValueEVN.CRT
92. Observation.referenceRange.observationRange.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

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
93. Observation.referenceRange.observationRange.code
Control0..0
BindingThe codes SHALL be taken from v3 Code System ActCode; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

This observationRange SHALL NOT contain [0..0] code (CONF:1198-7152).

94. Observation.referenceRange.observationRange.text
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
95. Observation.referenceRange.observationRange.value
Control1..1
TypeChoice of: http://hl7.org/fhir/cda/StructureDefinition/BL, http://hl7.org/fhir/cda/StructureDefinition/ED, http://hl7.org/fhir/cda/StructureDefinition/ST, http://hl7.org/fhir/cda/StructureDefinition/CD, http://hl7.org/fhir/cda/StructureDefinition/CV, http://hl7.org/fhir/cda/StructureDefinition/CE, http://hl7.org/fhir/cda/StructureDefinition/SC, http://hl7.org/fhir/cda/StructureDefinition/II, http://hl7.org/fhir/cda/StructureDefinition/TEL, http://hl7.org/fhir/cda/StructureDefinition/AD, http://hl7.org/fhir/cda/StructureDefinition/EN, http://hl7.org/fhir/cda/StructureDefinition/INT, http://hl7.org/fhir/cda/StructureDefinition/REAL, http://hl7.org/fhir/cda/StructureDefinition/PQ, http://hl7.org/fhir/cda/StructureDefinition/MO, http://hl7.org/fhir/cda/StructureDefinition/TS, http://hl7.org/fhir/cda/StructureDefinition/IVL-PQ, http://hl7.org/fhir/cda/StructureDefinition/IVL-TS, http://hl7.org/fhir/cda/StructureDefinition/PIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/EIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/SXPR-TS
Requirements

This observationRange SHALL contain exactly one [1..1] value (CONF:1198-32175).

96. Observation.referenceRange.observationRange.interpretationCode
Control0..1
BindingThe codes SHALL be taken from ObservationInterpretation
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE