Consolidated CDA Release 2.2
2.2 - CI Build

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: Indication

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.19 | Version: 2.2
Active as of 2022-05-13 | Computable Name: Indication
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09

This template represents the rationale for an action such as an encounter, a medication administration, or a procedure. The id element can be used to reference a problem recorded elsewhere in the document, or can be used with a code and value to record the problem. Indications for treatment are not laboratory results; rather the problem associated with the laboratory result should be cited (e.g., hypokalemia instead of a laboratory result of Potassium 2.0 mEq/L). Use the Drug Monitoring Act [templateId 2.16.840.1.113883.10.20.22.4.123] to indicate if a particular drug needs special monitoring (e.g., anticoagulant therapy). Use Precondition for Substance Administration (V2) [templateId 2.16.840.1.113883.10.20.22.4.25.2] to represent that a medication is to be administered only when the associated criteria are met.

Usage:

- Use this Resource Profile: Procedure Indications Section, Procedure Activity Act, Planned Immunization Activity, Procedure Activity Observation, Procedure Activity Procedure, Patient Referral Act, Medication Activity, Planned Act, Planned Encounter, Planned Procedure, Planned Medication Activity, Planned Supply, Planned Observation, Encounter Activity, Immunization Activity

### Formal Views of Profile Content

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

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from CDAR2.Observation

Summary

Mandatory: 9 elements

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

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, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.19
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id |  | 1..* | II | If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
code |  | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (example)
statusCode |  | 1..1 | CS |
code |  | 1..1 | string | Required Pattern: completed
effectiveTime |  | 0..1 | IVL_TS |
value |  | 0..1 | CD | Binding: Problem (preferred)
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, value:extension
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: 2.16.840.1.113883.10.20.22.4.19
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id |  | 1..* | II | If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
code |  | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (example)
derivationExpr |  | 0..1 | ED |
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 |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 0..1 | CD | Binding: Problem (preferred)
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
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 |
entryRelationship | I | 0..* | Element |
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 |
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 |
typeCode |  | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation |
Documentation for this format

This structure is derived from CDAR2.Observation

Summary

Mandatory: 9 elements

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

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, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.19
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id |  | 1..* | II | If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
code |  | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (example)
statusCode |  | 1..1 | CS |
code |  | 1..1 | string | Required Pattern: completed
effectiveTime |  | 0..1 | IVL_TS |
value |  | 0..1 | CD | Binding: Problem (preferred)
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, value:extension
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: 2.16.840.1.113883.10.20.22.4.19
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id |  | 1..* | II | If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
code |  | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (example)
derivationExpr |  | 0..1 | ED |
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 |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 0..1 | CD | Binding: Problem (preferred)
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
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 |
entryRelationship | I | 0..* | Element |
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 |
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 |
typeCode |  | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Pattern: OBS
Observation.templateId:primary.nullFlavor | required | NullFlavor
Observation.code | example | Problem Type (SNOMEDCT)
Observation.statusCode | required | ActStatus
Observation.statusCode.nullFlavor | required | NullFlavor
Observation.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage
Observation.value | preferred | Problem
Observation.interpretationCode | required | ObservationInterpretation
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

#### Constraints

Id | Grade | Path | Details | Requirements
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 |