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: Functional Status Observation

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.67 Version: 2.2
Active as of 2022-05-13 Computable Name: FunctionalStatusObservation
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.67:2014-06-09

This template represents the patient’s physical function (e.g., mobility status, instrumental activities of daily living, self-care status) and problems that limit function (dyspnea, dysphagia). The template may include assessment scale observations, identify supporting caregivers, and provide information about non-medicinal supplies. This template is used to represent physical or developmental function of all patient populations.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Observation

Summary

Mandatory: 13 elements (6 nested mandatory elements)

Structures

This structure refers to these other structures:

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 profile:supply, profile:observation

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.67
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
.... code 1..1stringRequired Pattern: 54522-8
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TS
... value I1..1BL, 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_PQ1098-14234: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-14234).
... author 0..*AuthorParticipation
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:supply, profile:observation
.... entryRelationship:nonMedSupply 0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... supply 1..1NonMedicinalSupplyActivity
.... entryRelationship:caregiverCharacteristics 0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:assessmentScaleObservation 0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1AssessmentScaleObservation
... referenceRange 0..*ElementreferenceRange could be used to represent normal or expected capability for the function being evaluated.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.67
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 54522-8
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value I1..11098-14234: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-14234).
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipation
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:supply, profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:nonMedSupply I0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... supply 1..1NonMedicinalSupplyActivity
.... entryRelationship:caregiverCharacteristics I0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:assessmentScaleObservation I0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleObservation
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*ElementreferenceRange could be used to represent normal or expected capability for the function being evaluated.
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

This structure is derived from CDAR2.Observation

Summary

Mandatory: 13 elements (6 nested mandatory elements)

Structures

This structure refers to these other structures:

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 profile:supply, profile:observation

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.67
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
.... code 1..1stringRequired Pattern: 54522-8
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TS
... value I1..1BL, 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_PQ1098-14234: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-14234).
... author 0..*AuthorParticipation
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:supply, profile:observation
.... entryRelationship:nonMedSupply 0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... supply 1..1NonMedicinalSupplyActivity
.... entryRelationship:caregiverCharacteristics 0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:assessmentScaleObservation 0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1AssessmentScaleObservation
... referenceRange 0..*ElementreferenceRange could be used to represent normal or expected capability for the function being evaluated.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.67
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 54522-8
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value I1..11098-14234: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-14234).
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipation
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:supply, profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:nonMedSupply I0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... supply 1..1NonMedicinalSupplyActivity
.... entryRelationship:caregiverCharacteristics I0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CaregiverCharacteristics
.... entryRelationship:assessmentScaleObservation I0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleObservation
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*ElementreferenceRange could be used to represent normal or expected capability for the function being evaluated.
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePathDetailsRequirements
1098-14234warningObservation.valueIf xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-14234).
:
obs-er-1errorObservation.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:nonMedSupplyOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:caregiverCharacteristicsOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1errorObservation.entryRelationship:assessmentScaleObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1