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/2.16.840.1.113883.10.20.22.4.69 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: AssessmentScaleObservation | |||
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.4.69 |
An assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
Summary
Mandatory: 10 elements (3 nested mandatory elements)
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:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
effectiveTime | 1..1 | IVL_TS | Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
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, RTO_PQ_PQ | ||
interpretationCode | 0..* | CE | ||
translation | 0..* | CD | ||
author | 0..* | Author | ||
Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
entryRelationship:supporting | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: COMP | |
observation | 1..1 | AssessmentScaleSupportingObservation | ||
referenceRange | 0..* | Element | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
observationRange | 1..1 | ObservationRange | ||
text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
reference | 0..1 | TEL | ||
value | I | 0..1 | uri | 81-16804: 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:81-16804). |
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: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: 2.16.840.1.113883.10.20.22.4.69 | |
extension | 0..1 | string | ||
id | 1..* | II | ||
code | I | 1..1 | CD | Binding: ObservationType (extensible) 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
text | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: completed | |
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 clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
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 | |||
value | RTO_PQ_PQ | |||
interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | ||
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..* | CE | Binding: ObservationMethod (extensible) | |
targetSiteCode | 0..* | 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..* | Author | ||
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 | ||
Slices for entryRelationship | I | 0..* | Element | Slice: Unordered, Open by profile:observation |
entryRelationship:All Slices | Content/Rules for all slices | |||
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 | ||
entryRelationship:supporting | I | 0..* | Element | |
typeCode | 1..1 | code | Required Pattern: COMP | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
observation | 1..1 | AssessmentScaleSupportingObservation | ||
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 | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
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 | ||
code | 0..1 | CD | Binding: v3 Code System ActCode (extensible) | |
text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
charset | 0..1 | code | ||
compression | 0..1 | code | Binding: CompressionAlgorithm (required) | |
integrityCheck | 0..1 | base64Binary | ||
integrityCheckAlgorithm | 0..1 | code | Binding: IntegrityCheckAlgorithm (required) | |
language | 0..1 | code | ||
mediaType | 0..1 | code | ||
representation | 0..1 | code | ||
data[x] | 0..1 | |||
dataString | string | |||
dataBase64Binary | base64Binary | |||
reference | 0..1 | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | I | 0..1 | uri | 81-16804: 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:81-16804). |
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..* | code | Binding: AddressUse (required) | |
thumbnail | 0..1 | ED | ||
value | 0..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: 10 elements (3 nested mandatory elements)
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:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
effectiveTime | 1..1 | IVL_TS | Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
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, RTO_PQ_PQ | ||
interpretationCode | 0..* | CE | ||
translation | 0..* | CD | ||
author | 0..* | Author | ||
Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
entryRelationship:supporting | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: COMP | |
observation | 1..1 | AssessmentScaleSupportingObservation | ||
referenceRange | 0..* | Element | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
observationRange | 1..1 | ObservationRange | ||
text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
reference | 0..1 | TEL | ||
value | I | 0..1 | uri | 81-16804: 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:81-16804). |
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: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: 2.16.840.1.113883.10.20.22.4.69 | |
extension | 0..1 | string | ||
id | 1..* | II | ||
code | I | 1..1 | CD | Binding: ObservationType (extensible) 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
text | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: completed | |
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 clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
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 | |||
value | RTO_PQ_PQ | |||
interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | ||
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..* | CE | Binding: ObservationMethod (extensible) | |
targetSiteCode | 0..* | 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..* | Author | ||
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 | ||
Slices for entryRelationship | I | 0..* | Element | Slice: Unordered, Open by profile:observation |
entryRelationship:All Slices | Content/Rules for all slices | |||
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 | ||
entryRelationship:supporting | I | 0..* | Element | |
typeCode | 1..1 | code | Required Pattern: COMP | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
observation | 1..1 | AssessmentScaleSupportingObservation | ||
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 | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
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 | ||
code | 0..1 | CD | Binding: v3 Code System ActCode (extensible) | |
text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
charset | 0..1 | code | ||
compression | 0..1 | code | Binding: CompressionAlgorithm (required) | |
integrityCheck | 0..1 | base64Binary | ||
integrityCheckAlgorithm | 0..1 | code | Binding: IntegrityCheckAlgorithm (required) | |
language | 0..1 | code | ||
mediaType | 0..1 | code | ||
representation | 0..1 | code | ||
data[x] | 0..1 | |||
dataString | string | |||
dataBase64Binary | base64Binary | |||
reference | 0..1 | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | I | 0..1 | uri | 81-16804: 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:81-16804). |
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..* | code | Binding: AddressUse (required) | |
thumbnail | 0..1 | ED | ||
value | 0..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.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.interpretationCode.nullFlavor | required | NullFlavor |
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.code | extensible | ActCode |
Observation.referenceRange.observationRange.text.nullFlavor | required | NullFlavor |
Observation.referenceRange.observationRange.text.compression | required | CompressionAlgorithm |
Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
Observation.referenceRange.observationRange.text.reference.nullFlavor | required | NullFlavor |
Observation.referenceRange.observationRange.text.reference.use | required | AddressUse |
Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
Id | Grade | Path | Details | Requirements |
81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
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 | |
obs-er-1 | error | Observation.entryRelationship:supporting | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : |