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: SOP Instance Observation

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.8 Version: 2.2
Active as of 2022-05-13 Computable Name: SOPInstanceObservation
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.6.2.8

A SOP Instance Observation contains the DICOM Service Object Pair (SOP) Instance information for referenced DICOM composite objects. The SOP Instance act class is used to reference both image and non-image DICOM instances. The text attribute contains the DICOM WADO reference.

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: 6 elements (8 nested mandatory elements)
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.entryRelationship is sliced based on the value of value:typeCode

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: DGIMG
... moodCode 1..1codeRequired Pattern: EVN
... id 1..*IIThe @root contains an OID representing the DICOM SOP Instance UID
.... code I1..1string81-19226: @code is an OID for a valid SOP class name UID (CONF:81-19226).
.... codeSystem 1..1stringRequired Pattern: 1.2.840.10008.2.6.1
... text 0..1ED
.... mediaType 1..1codeRequired Pattern: application/dicom
.... reference I1..1TEL81-9249: **SHALL** contain a @value that contains a WADO reference as a URI (CONF:81-9249).
... effectiveTime 0..1IVL_TS
.... value 1..1dateTime
.... low 0..0
.... high 0..0
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by value:typeCode
.... entryRelationship:subject 0..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
.... entryRelationship:purposeofReferenceObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1PurposeofReferenceObservation
.... entryRelationship:referencedFramesObservation I0..*Element81-9263: This entryRelationship SHALL be present if the referenced DICOM object is a multiframe object and the reference does not apply to all frames (CONF:81-9263).
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1ReferencedFramesObservation

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: DGIMG
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... templateId 0..*II
... id 1..*IIThe @root contains an OID representing the DICOM SOP Instance UID
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code I1..1string81-19226: @code is an OID for a valid SOP class name UID (CONF:81-19226).
.... codeSystem 1..1stringRequired Pattern: 1.2.840.10008.2.6.1
.... 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
.... 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 1..1codeRequired Pattern: application/dicom
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference I1..1TEL81-9249: **SHALL** contain a @value that contains a WADO reference as a URI (CONF:81-9249).
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 1..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..*
.... 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..*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
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by value:typeCode
.... 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:subject I0..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... 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:purposeofReferenceObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PurposeofReferenceObservation
.... entryRelationship:referencedFramesObservation I0..*Element81-9263: This entryRelationship SHALL be present if the referenced DICOM object is a multiframe object and the reference does not apply to all frames (CONF:81-9263).
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReferencedFramesObservation
... 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: 6 elements (8 nested mandatory elements)
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.entryRelationship is sliced based on the value of value:typeCode

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: DGIMG
... moodCode 1..1codeRequired Pattern: EVN
... id 1..*IIThe @root contains an OID representing the DICOM SOP Instance UID
.... code I1..1string81-19226: @code is an OID for a valid SOP class name UID (CONF:81-19226).
.... codeSystem 1..1stringRequired Pattern: 1.2.840.10008.2.6.1
... text 0..1ED
.... mediaType 1..1codeRequired Pattern: application/dicom
.... reference I1..1TEL81-9249: **SHALL** contain a @value that contains a WADO reference as a URI (CONF:81-9249).
... effectiveTime 0..1IVL_TS
.... value 1..1dateTime
.... low 0..0
.... high 0..0
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by value:typeCode
.... entryRelationship:subject 0..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
.... entryRelationship:purposeofReferenceObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1PurposeofReferenceObservation
.... entryRelationship:referencedFramesObservation I0..*Element81-9263: This entryRelationship SHALL be present if the referenced DICOM object is a multiframe object and the reference does not apply to all frames (CONF:81-9263).
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1ReferencedFramesObservation

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: DGIMG
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... templateId 0..*II
... id 1..*IIThe @root contains an OID representing the DICOM SOP Instance UID
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code I1..1string81-19226: @code is an OID for a valid SOP class name UID (CONF:81-19226).
.... codeSystem 1..1stringRequired Pattern: 1.2.840.10008.2.6.1
.... 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
.... 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 1..1codeRequired Pattern: application/dicom
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference I1..1TEL81-9249: **SHALL** contain a @value that contains a WADO reference as a URI (CONF:81-9249).
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 1..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..*
.... 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..*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
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by value:typeCode
.... 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:subject I0..*Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... 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:purposeofReferenceObservation I0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PurposeofReferenceObservation
.... entryRelationship:referencedFramesObservation I0..*Element81-9263: This entryRelationship SHALL be present if the referenced DICOM object is a multiframe object and the reference does not apply to all frames (CONF:81-9263).
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReferencedFramesObservation
... 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: DGIMG
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.text.nullFlavorrequiredNullFlavor
Observation.text.compressionrequiredCompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.statusCoderequiredActStatus
Observation.effectiveTime.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
81-19226errorObservation.code.code@code is an OID for a valid SOP class name UID (CONF:81-19226).
:
81-9249errorObservation.text.reference**SHALL** contain a @value that contains a WADO reference as a URI (CONF:81-9249).
:
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:subjectOnly 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:purposeofReferenceObservationOnly 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:referencedFramesObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
81-9263warningObservation.entryRelationship:referencedFramesObservationThis entryRelationship SHALL be present if the referenced DICOM object is a multiframe object and the reference does not apply to all frames (CONF:81-9263).
: