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 2.16.840.1.113883.10.20.22.4.38 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:1198-8548). |
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:1198-8549). |
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:
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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:1198-8550) 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="2.16.840.1.113883.10.20.22.4.38" (CONF:1198-10526). |
Pattern Value | 2.16.840.1.113883.10.20.22.4.38 |
13. Observation.templateId:primary.extension | |
Definition | A character string as a unique identifier within the scope of the identifier root. |
Control | 1..1 |
Type | string |
Requirements | SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32495). |
Pattern Value | 2015-08-01 |
14. Observation.id | |
Control | 1..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/II |
Requirements | SHALL contain at least one [1..*] id (CONF:1198-8551). |
15. Observation.code | |
Control | 1..1 |
Binding | The codes SHOULD be taken from Social History Type |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
Requirements | SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Social History Type urn:oid:2.16.840.1.113883.3.88.12.80.60 DYNAMIC (CONF:1198-8558). |
Invariants | Defined on this element 1198-32951: 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:1198-32951). (: ) |
16. Observation.derivationExpr | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ST |
17. Observation.text | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
18. 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:1198-8553). |
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. |
Control | 0..1 |
Binding | The codes SHALL be taken from NullFlavor |
Type | code |
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. |
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:1198-19117). |
Pattern Value | completed |
21. Observation.statusCode.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 0..0 |
Type | string |
22. Observation.statusCode.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..0 |
Type | string |
23. Observation.statusCode.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..0 |
Type | string |
24. 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 |
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. |
Control | 0..1 |
Type | string |
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. |
Control | 0..1 |
Type | string |
27. 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 |
28. 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 |
29. 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 |
30. Observation.effectiveTime | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/IVL-TS |
Requirements | SHALL contain exactly one [1..1] effectiveTime (CONF:1198-31868). |
31. 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 |
32. Observation.repeatNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/IVL-INT |
33. Observation.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from HumanLanguage |
Type | http://hl7.org/fhir/cda/StructureDefinition/CS |
34. Observation.value | |
Control | 0..1 |
Type | Choice 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 | SHOULD contain zero or one [0..1] value (CONF:1198-8559). |
Invariants | Defined on this element 1198-8555: 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:1198-8555). (: ) |
35. Observation.interpretationCode | |
Control | 0..* |
Binding | The codes SHALL be taken from ObservationInterpretation |
Type | http://hl7.org/fhir/cda/StructureDefinition/CE |
36. 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 |
37. Observation.targetSiteCode | |
Definition | Drawn from concept domain ActSite |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
38. Observation.subject | |
Control | 0..1 |
Type | Element |
39. Observation.subject.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ParticipationTargetSubject |
Type | code |
Default Value | SBJ |
Fixed Value | SBJ |
40. Observation.subject.contextControlCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ContextControl |
Type | code |
Default Value | OP |
Fixed Value | OP |
41. 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 |
42. Observation.subject.relatedSubject | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RelatedSubject |
43. Observation.specimen | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Specimen |
44. Observation.performer | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Performer2 |
45. Observation.author | |
Control | 0..* |
Type | http://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:1198-31869). |
46. Observation.informant | |
Control | 0..* |
Type | Element |
47. Observation.informant.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ParticipationInformationGenerator |
Type | code |
Default Value | INF |
Fixed Value | INF |
48. Observation.informant.contextControlCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ContextControl |
Type | code |
Default Value | OP |
Fixed Value | OP |
49. Observation.informant.assignedEntity | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/AssignedEntity |
50. Observation.informant.relatedEntity | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RelatedEntity |
51. Observation.participant | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Participant2 |
52. 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) |
53. Observation.entryRelationship.typeCode | |
Control | 1..1 |
Type | code |
54. Observation.entryRelationship.inversionInd | |
Control | 0..1 |
Type | boolean |
55. Observation.entryRelationship.contextConductionInd | |
Control | 1..1 |
Type | boolean |
Default Value | true |
56. Observation.entryRelationship.sequenceNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/INT |
57. Observation.entryRelationship.negationInd | |
Control | 0..1 |
Type | boolean |
58. Observation.entryRelationship.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
59. Observation.entryRelationship.observation | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Observation |
60. Observation.entryRelationship.regionOfInterest | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest |
61. Observation.entryRelationship.observationMedia | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationMedia |
62. Observation.entryRelationship.substanceAdministration | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration |
63. Observation.entryRelationship.supply | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Supply |
64. Observation.entryRelationship.procedure | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Procedure |
65. Observation.entryRelationship.encounter | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Encounter |
66. Observation.entryRelationship.organizer | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Organizer |
67. Observation.entryRelationship.act | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Act |
68. Observation.reference | |
Control | 0..* |
Type | Element |
69. Observation.reference.typeCode | |
Control | 1..1 |
Type | code |
70. Observation.reference.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
71. Observation.reference.externalAct | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalAct |
72. Observation.reference.externalObservation | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalObservation |
73. Observation.reference.externalProcedure | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure |
74. Observation.reference.externalDocument | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalDocument |
75. Observation.precondition | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Precondition |
76. Observation.referenceRange | |
Control | 0..* |
Type | Element |
77. Observation.referenceRange.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ActRelationshipPertains |
Type | code |
Default Value | REFV |
Fixed Value | REFV |
78. Observation.referenceRange.observationRange | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationRange |