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 2.16.840.1.113883.10.20.22.4.78 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:1098-14806). |
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:1098-14807). |
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:
|
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:1098-14815) 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="2.16.840.1.113883.10.20.22.4.78" (CONF:1098-14816). |
Pattern Value | 2.16.840.1.113883.10.20.22.4.78 |
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="2014-06-09" (CONF:1098-32573). |
Pattern Value | 2014-06-09 |
14. Observation.id | |
Control | 1..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/II |
Requirements | SHALL contain at least one [1..*] id (CONF:1098-32401). |
15. Observation.code | |
Control | 1..1 |
Binding | The codes SHALL be taken from ObservationType; other codes may be used where these codes are not suitable |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
Requirements | SHALL contain exactly one [1..1] code (CONF:1098-19170). |
16. Observation.code.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 |
17. Observation.code.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 code SHALL contain exactly one [1..1] @code="72166-2" Tobacco smoking status NHIS (CONF:1098-31039). |
Pattern Value | 72166-2 |
18. Observation.code.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 1..1 |
Type | string |
Requirements | This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32157). |
Pattern Value | 2.16.840.1.113883.6.1 |
19. Observation.code.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..1 |
Type | string |
20. Observation.code.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..1 |
Type | string |
21. Observation.code.displayName | |
Definition | A name or title for the code, under which the sending system shows the code value to its users. |
Control | 0..1 |
Type | string |
22. Observation.code.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 |
23. Observation.code.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 |
24. Observation.code.originalText | |
Definition | The text or phrase used as the basis for the coding. |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
25. Observation.code.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CR |
26. Observation.code.translation | |
Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
27. Observation.derivationExpr | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ST |
28. Observation.text | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
29. 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:1098-14809). |
30. 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 |
31. 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:1098-19116). |
Pattern Value | completed |
32. Observation.statusCode.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 0..0 |
Type | string |
33. Observation.statusCode.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..0 |
Type | string |
34. Observation.statusCode.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..0 |
Type | string |
35. 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 |
36. 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 |
37. 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 |
38. 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 |
39. 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 |
40. 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 |
41. Observation.effectiveTime | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/IVL-TS |
Requirements | SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31928). |
42. Observation.effectiveTime.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 |
43. Observation.effectiveTime.value | |
Definition | A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression. |
Control | 0..1 |
Type | dateTime |
44. Observation.effectiveTime.inclusive | |
Definition | Specifies whether the limit is included in the interval (interval is closed) or excluded from the interval (interval is open). |
Control | 0..1 |
Type | boolean |
45. Observation.effectiveTime.operator | |
Definition | A code specifying whether the set component is included (union) or excluded (set-difference) from the set, or other set operations with the current set component and the set as constructed from the representation stream up to the current point. |
Control | 0..1 |
Type | code |
46. Observation.effectiveTime.low | |
Definition | This is the low limit of the interval. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/TS |
Requirements | This effectiveTime SHALL NOT contain [0..0] low (CONF:1098-32894). |
47. Observation.effectiveTime.high | |
Definition | This is the high limit of the interval. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/TS |
Requirements | This effectiveTime SHALL NOT contain [0..0] high (CONF:1098-32896). |
48. Observation.effectiveTime.width | |
Definition | The difference between high and low boundary. The purpose of distinguishing a width property is to handle all cases of incomplete information symmetrically. In any interval representation only two of the three properties high, low, and width need to be stated and the third can be derived. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/PQ |
Requirements | This effectiveTime SHALL NOT contain [0..0] width (CONF:1098-32895). |
49. Observation.effectiveTime.center | |
Definition | The arithmetic mean of the interval (low plus high divided by 2). The purpose of distinguishing the center as a semantic property is for conversions of intervals from and to point values. |
Control | 0..0 |
Type | http://hl7.org/fhir/cda/StructureDefinition/TS |
Requirements | This effectiveTime SHALL NOT contain [0..0] center (CONF:1098-32897). |
50. 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 |
51. Observation.repeatNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/IVL-INT |
52. Observation.languageCode | |
Control | 0..1 |
Binding | The codes SHALL be taken from HumanLanguage |
Type | http://hl7.org/fhir/cda/StructureDefinition/CS |
53. Observation.value | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
Requirements | SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1098-14810). |
Invariants | Defined on this element 1098-31019: If the patient's current smoking status is unknown, @code **SHALL** contain '266927001' (Unknown if ever smoked) from ValueSet Current Smoking Status (2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01) (CONF:1098-31019). (: ) |
54. Observation.value.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 |
55. Observation.value.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 |
Binding | The codes SHALL be taken from Smoking Status |
Type | string |
Requirements | This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Smoking Status urn:oid:2.16.840.1.113883.11.20.9.38 DYNAMIC (CONF:1098-14817). |
56. Observation.value.codeSystem | |
Definition | Specifies the code system that defines the code. |
Control | 0..1 |
Type | string |
57. Observation.value.codeSystemName | |
Definition | The common name of the coding system. |
Control | 0..1 |
Type | string |
58. Observation.value.codeSystemVersion | |
Definition | If applicable, a version descriptor defined specifically for the given code system. |
Control | 0..1 |
Type | string |
59. Observation.value.displayName | |
Definition | A name or title for the code, under which the sending system shows the code value to its users. |
Control | 0..1 |
Type | string |
60. Observation.value.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 |
61. Observation.value.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 |
62. Observation.value.originalText | |
Definition | The text or phrase used as the basis for the coding. |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ED |
63. Observation.value.qualifier | |
Definition | Specifies additional codes that increase the specificity of the the primary code. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CR |
64. Observation.value.translation | |
Definition | A set of other concept descriptors that translate this concept descriptor into other code systems. |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
65. Observation.interpretationCode | |
Control | 0..* |
Binding | The codes SHALL be taken from ObservationInterpretation |
Type | http://hl7.org/fhir/cda/StructureDefinition/CE |
66. 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 |
67. Observation.targetSiteCode | |
Definition | Drawn from concept domain ActSite |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/CD |
68. Observation.subject | |
Control | 0..1 |
Type | Element |
69. Observation.subject.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ParticipationTargetSubject |
Type | code |
Default Value | SBJ |
Fixed Value | SBJ |
70. Observation.subject.contextControlCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ContextControl |
Type | code |
Default Value | OP |
Fixed Value | OP |
71. 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 |
72. Observation.subject.relatedSubject | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RelatedSubject |
73. Observation.specimen | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Specimen |
74. Observation.performer | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Performer2 |
75. 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:1098-31148). |
76. Observation.informant | |
Control | 0..* |
Type | Element |
77. Observation.informant.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ParticipationInformationGenerator |
Type | code |
Default Value | INF |
Fixed Value | INF |
78. Observation.informant.contextControlCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ContextControl |
Type | code |
Default Value | OP |
Fixed Value | OP |
79. Observation.informant.assignedEntity | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/AssignedEntity |
80. Observation.informant.relatedEntity | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RelatedEntity |
81. Observation.participant | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Participant2 |
82. 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) |
83. Observation.entryRelationship.typeCode | |
Control | 1..1 |
Type | code |
84. Observation.entryRelationship.inversionInd | |
Control | 0..1 |
Type | boolean |
85. Observation.entryRelationship.contextConductionInd | |
Control | 1..1 |
Type | boolean |
Default Value | true |
86. Observation.entryRelationship.sequenceNumber | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/INT |
87. Observation.entryRelationship.negationInd | |
Control | 0..1 |
Type | boolean |
88. Observation.entryRelationship.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
89. Observation.entryRelationship.observation | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Observation |
90. Observation.entryRelationship.regionOfInterest | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest |
91. Observation.entryRelationship.observationMedia | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationMedia |
92. Observation.entryRelationship.substanceAdministration | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration |
93. Observation.entryRelationship.supply | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Supply |
94. Observation.entryRelationship.procedure | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Procedure |
95. Observation.entryRelationship.encounter | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Encounter |
96. Observation.entryRelationship.organizer | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Organizer |
97. Observation.entryRelationship.act | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/Act |
98. Observation.reference | |
Control | 0..* |
Type | Element |
99. Observation.reference.typeCode | |
Control | 1..1 |
Type | code |
100. Observation.reference.seperatableInd | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/BL |
101. Observation.reference.externalAct | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalAct |
102. Observation.reference.externalObservation | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalObservation |
103. Observation.reference.externalProcedure | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure |
104. Observation.reference.externalDocument | |
Control | 0..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ExternalDocument |
105. Observation.precondition | |
Control | 0..* |
Type | http://hl7.org/fhir/cda/StructureDefinition/Precondition |
106. Observation.referenceRange | |
Control | 0..* |
Type | Element |
107. Observation.referenceRange.typeCode | |
Control | 1..1 |
Binding | The codes SHALL be taken from ActRelationshipPertains |
Type | code |
Default Value | REFV |
Fixed Value | REFV |
108. Observation.referenceRange.observationRange | |
Control | 1..1 |
Type | http://hl7.org/fhir/cda/StructureDefinition/ObservationRange |