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
Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.2 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: ResultObservation | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2015-08-01 |
This template represents the results of a laboratory, radiology, or other study performed on a patient.
The result observation includes a statusCode to allow recording the status of an observation. Pending results (e.g., a test has been run but results have not been reported yet) should be represented as active ActStatus.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
Summary
Mandatory: 11 elements (3 nested mandatory elements)
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | ||
classCode | 1..1 | code | Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 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). |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Binding: Result Status (required) | |
effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
value | I | 1..1 | BL, ED, ED, 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 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 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). 1198-31484: 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). |
interpretationCode | 0..* | CE | ||
code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
methodCode | 0..1 | CE | ||
targetSiteCode | 0..1 | CD | ||
author | 0..* | AuthorParticipation | ||
referenceRange | 0..* | Element | ||
observationRange | 1..1 | ObservationRange | ||
code | 0..0 | |||
value | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | ||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | ||
classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
negationInd | 0..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | I | 1..1 | CD | Binding: ObservationType (extensible) 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). |
derivationExpr | 0..1 | ED | ||
text | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Result Status (required) | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
value | I | 1..1 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 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). 1198-31484: 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). | |
value | BL | |||
value | ED | |||
value | ED | |||
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) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
targetSiteCode | 0..1 | CD | ||
subject | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
relatedSubject | 1..1 | RelatedSubject | ||
specimen | 0..* | Specimen | ||
performer | 0..* | Performer2 | ||
author | 0..* | AuthorParticipation | ||
informant | 0..* | Element | ||
typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 0..1 | RelatedEntity | ||
participant | 0..* | Participant2 | ||
entryRelationship | I | 0..* | Element | |
typeCode | 1..1 | code | ||
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
(Choice of one) | 1..1 | |||
observation | 0..1 | Observation | ||
regionOfInterest | 0..1 | RegionOfInterest | ||
observationMedia | 0..1 | ObservationMedia | ||
substanceAdministration | 0..1 | SubstanceAdministration | ||
supply | 0..1 | Supply | ||
procedure | 0..1 | Procedure | ||
encounter | 0..1 | Encounter | ||
organizer | 0..1 | Organizer | ||
act | 0..1 | Act | ||
reference | 0..* | Element | ||
typeCode | 1..1 | code | ||
seperatableInd | 0..1 | BL | ||
externalAct | 0..1 | ExternalAct | ||
externalObservation | 0..1 | ExternalObservation | ||
externalProcedure | 0..1 | ExternalProcedure | ||
externalDocument | 0..1 | ExternalDocument | ||
precondition | 0..* | Precondition | ||
referenceRange | 0..* | Element | ||
typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
observationRange | 1..1 | ObservationRange | ||
classCode | 1..1 | code | Binding: ActClassObservation (required) | |
moodCode | 1..1 | code | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
templateId | 0..* | II | ||
text | 0..1 | ED | ||
value | 1..1 | |||
value | BL | |||
value | ED | |||
value | ED | |||
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 | |||
interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
Documentation for this format |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 11 elements (3 nested mandatory elements)
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | ||
classCode | 1..1 | code | Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 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). |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Binding: Result Status (required) | |
effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
value | I | 1..1 | BL, ED, ED, 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 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 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). 1198-31484: 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). |
interpretationCode | 0..* | CE | ||
code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
methodCode | 0..1 | CE | ||
targetSiteCode | 0..1 | CD | ||
author | 0..* | AuthorParticipation | ||
referenceRange | 0..* | Element | ||
observationRange | 1..1 | ObservationRange | ||
code | 0..0 | |||
value | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | ||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | ||
classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
negationInd | 0..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | I | 1..1 | CD | Binding: ObservationType (extensible) 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). |
derivationExpr | 0..1 | ED | ||
text | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Result Status (required) | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
value | I | 1..1 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 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). 1198-31484: 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). | |
value | BL | |||
value | ED | |||
value | ED | |||
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) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
targetSiteCode | 0..1 | CD | ||
subject | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
relatedSubject | 1..1 | RelatedSubject | ||
specimen | 0..* | Specimen | ||
performer | 0..* | Performer2 | ||
author | 0..* | AuthorParticipation | ||
informant | 0..* | Element | ||
typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 0..1 | RelatedEntity | ||
participant | 0..* | Participant2 | ||
entryRelationship | I | 0..* | Element | |
typeCode | 1..1 | code | ||
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
(Choice of one) | 1..1 | |||
observation | 0..1 | Observation | ||
regionOfInterest | 0..1 | RegionOfInterest | ||
observationMedia | 0..1 | ObservationMedia | ||
substanceAdministration | 0..1 | SubstanceAdministration | ||
supply | 0..1 | Supply | ||
procedure | 0..1 | Procedure | ||
encounter | 0..1 | Encounter | ||
organizer | 0..1 | Organizer | ||
act | 0..1 | Act | ||
reference | 0..* | Element | ||
typeCode | 1..1 | code | ||
seperatableInd | 0..1 | BL | ||
externalAct | 0..1 | ExternalAct | ||
externalObservation | 0..1 | ExternalObservation | ||
externalProcedure | 0..1 | ExternalProcedure | ||
externalDocument | 0..1 | ExternalDocument | ||
precondition | 0..* | Precondition | ||
referenceRange | 0..* | Element | ||
typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
observationRange | 1..1 | ObservationRange | ||
classCode | 1..1 | code | Binding: ActClassObservation (required) | |
moodCode | 1..1 | code | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
templateId | 0..* | II | ||
text | 0..1 | ED | ||
value | 1..1 | |||
value | BL | |||
value | ED | |||
value | ED | |||
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 | |||
interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Pattern: OBS |
Observation.templateId:primary.nullFlavor | required | NullFlavor |
Observation.code | extensible | ObservationType |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.statusCode.code | required | Result Status |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.interpretationCode.nullFlavor | required | NullFlavor |
Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
Observation.methodCode | extensible | ObservationMethod |
Observation.subject.typeCode | required | Fixed Value: SBJ |
Observation.subject.contextControlCode | required | Fixed Value: OP |
Observation.subject.awarenessCode | extensible | TargetAwareness |
Observation.informant.typeCode | required | Fixed Value: INF |
Observation.informant.contextControlCode | required | Fixed Value: OP |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
Id | Grade | Path | Details | Requirements |
1198-19212 | warning | Observation.code | 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). : | |
1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : | |
1198-31866 | warning | Observation.value | 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). : | |
1198-31484 | error | Observation.value | 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). : | |
obs-er-1 | error | Observation.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |