Consolidated CDA Release 2.2
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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 Problem Observation (DEPRECATED)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.68 Version: 2.2
Draft as of 2022-05-13 Computable Name: FunctionalStatusProblemObservation
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.68:2014-06-09

A functional status problem observation is a clinical statement that represents a patients functional perfomance and ability.

THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED.

Reason for deprecation: Functional Status Problem Observation has been merged, without loss of expressivity, into Functional Status Observation (2.16.840.1.113883.10.20.22.4.67:2014-06-09).

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: 10 elements (1 nested mandatory element)

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CD
.... code 0..1stringRequired Pattern: 248536006
... text 0..1ED
.... reference 0..1TEL
..... value I0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 0..1IVL_TS
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor I0..1code1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
... methodCode 0..1CE

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..1booleanUse negationInd="true" to indicate that the problem was not observed.
... 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: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1stringRequired Pattern: 248536006
.... codeSystem 0..1string
.... 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
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... charset 0..1code
.... compression 0..1codeBinding: CompressionAlgorithm (required)
.... integrityCheck 0..1base64Binary
.... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
.... language 0..1code
.... mediaType 0..1code
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference 0..1TEL
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value I0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... use 0..*codeBinding: AddressUse (required)
.... thumbnail 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 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor I0..1codeBinding: NullFlavor (required)
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
.... code 0..1string
.... codeSystem 0..1string
.... 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
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..1CEBinding: 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..*Author
... 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
... entryRelationship I0..*Element
.... 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
... 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..*Element
.... 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: 10 elements (1 nested mandatory element)

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension

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
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CD
.... code 0..1stringRequired Pattern: 248536006
... text 0..1ED
.... reference 0..1TEL
..... value I0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 0..1IVL_TS
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor I0..1code1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
... methodCode 0..1CE

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..1booleanUse negationInd="true" to indicate that the problem was not observed.
... 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: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1stringRequired Pattern: 248536006
.... codeSystem 0..1string
.... 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
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... charset 0..1code
.... compression 0..1codeBinding: CompressionAlgorithm (required)
.... integrityCheck 0..1base64Binary
.... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
.... language 0..1code
.... mediaType 0..1code
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference 0..1TEL
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value I0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... use 0..*codeBinding: AddressUse (required)
.... thumbnail 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 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor I0..1codeBinding: NullFlavor (required)
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
.... code 0..1string
.... codeSystem 0..1string
.... 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
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..1CEBinding: 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..*Author
... 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
... entryRelationship I0..*Element
.... 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
... 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..*Element
.... 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.text.nullFlavorrequiredNullFlavor
Observation.text.compressionrequiredCompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.text.reference.nullFlavorrequiredNullFlavor
Observation.text.reference.userequiredAddressUse
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage
Observation.valuepreferredProblem
Observation.value.nullFlavorrequiredNullFlavor
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
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
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